rKD3\         \'\w, 

Columbia  ®nibers;it|> 
int})eCitpofi^ettj|9orfe      .1 

^cfjool  of  ©ental  anb  0val  ^ur 


l^eference  l^ibrarp 


i 


THE 

PRINCIPLES  AND  PRACTICE 

OF  SURGERY 


THE 

PRINCIPLES  AND  PRACTICE 

OF  SURGERY 


BY 


HERMAN  A.  HAUBOLD,  M.D. 

CLINICAL  PROFESSOR  IX    SURGERY, 

NEW  YORK  UNIVERSITY  AND 

BELLEVUE      HOSPITAL 

ilEDICAL  COLLEGE, 

KEtr    YORK 


VOLUME  1 


WITE  633  ILLUSTRATIONS 


D.  APPLETON  AND  COMPANY 

NEW  YORK  LONDON 

1921 


COrYBIGHT,    1921,    BT 

D.  APPLETON  AND  COMPANY 


I/.  1 


PRIVTED  TV  THE  UNITED  STATES  OF  AMBBtCA 


TO 

GEORGE  DAVTD  STEWART,  M.D.,  F.A.C.S. 

THIS   BOOK   IS  DEDICATED 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/principlespractiOOhaub 


PREFACE 

Aside  from  the  many  to  Avhoin  the  writer  is  indebted  in  a  general 
way  (as  shown  by  the  large  number  of  bibliographical  references 
submitted)  especial  acknowledgment  is  made  to  Dr.  Henry  Charles 
Falk,  who  furnished  much  of  the  chapter  on  anesthesia  and  not  a 
little  of  the  material  upon  wiiich  the  surgery  of  the  thyroid  is  based : 
to  Dr.  Harry  Belleville  Eisberg,  who  supplied  a  great  part  of  the  data 
comprising  the  cliapters  on  the  surgery  of  the  thorax  and  that  de- 
voted to  the  female  organs  of  generation ;  and  to  Dr.  Charles  Vejvoda. 
who  labored  with  the  writer  on  the  surgery  of  the  pancreas. 

The  chapter  on  bacteriology  is  largely  taken  from  Hiss  and 
Zinsser.  Manifestly  a  general  surgeon  cannot  do  other  than  present 
the  subject  as  seen  through  the  eyes  of  the  bacteriologist.  The 
writer  regards  the  value  of  the  work  here  submitted  as  increased  by 
his  selection  in  this  connection. 

Especial  appreciation  is  extended  to  my  secretary.  ^Irs.  Carol  Case 
Dyett,  who  so  laboriously  deciphered  my  written  words  (many  thou- 
sancis  of  them)  and  transcribed  them  into  legibility  for  the  printer. 
Without  this  indefatigable  helper  this  work  would  not  be. 

The  result  of  the  publishers'  efforts  as  regards  the  mechanical  prob- 
lem presented  speaks  for  itself.     The  writer  wishes  to  thank  them 
for  an  agreeable  association  while  this  was  being  achieved. 

Those  of  my  readers  who  listened  to  my  spoken  words  in  the  old 
amphitheater  of  the  "University"  I  know  will  look  kindly  upon  my 
written  effort.  I  send  them  greetings.  The  others  I  ask  to  give 
this  work  the  consideration  it  merits.  I  send  it  forth  with  the  hope 
that  its  contents  will  be  of  aid  in  making  less  arduous  the  great 
problems  to  which  the  men  and  women  of  our  profession  devote  their 
lives. 

Herman  A.  Hatbot^d 


CHAPTER 

T.     Wounds 


CONTENTS 

PART  I 
Wounds 

PACE 

3 

General  Considerations 

Healing'  of  Wounds ' 

Primary  Union   

Secondary  Union   | 

Healing  of  Transplanted  Tissue 19 

ir.     Classification  of  Wounds 27 

III.  The  Treatment  of  Wounds ^•- 

IV.  General  Considerations  Regarding  Aseptic  Technic 80 

V.     Technic  of  Cleansing  the  Surfaces  of  the  Body 8.. 

The  Cleansing  of  the  Hands ^^ 

The  Cleansing  of  the  Skin  of  the  Operative  Area 80 

The  Cleansing  of  Mucous  Membranes 8" 

VI.     Sterilization  of  Instruments ^ 

VII.     Sterilization  of  Dressings,  Wipes.  Gowns,  etc. Ji 

VIII.     The  Sterilization  of  Suture  and  Ligature  Matenal 95 

General  Consideration   of  Absorbable  and  Non-Absorb- 

able  Suture  Material   95 

Absorbable  Suture  Material 95 

Catgut 

Kangaroo   Tendon    ^ 

Non- Absorbable  Suture  Material lOU 

Silkworm  Gut  J^" 

Silk ..J.. 

Pagenstecher  Thread   ;J":J 

Horsehair 

Silver  and  Gold  Wire j"^ 

IX.     Water  and  Cleansing  Solutions l'^-^ 

Water -  „„ 

Sterilization  of  Water    J^'^ 

Cleansing  Solutions  

X.     The  Operating  Room 

XL     The  Aseptic  Operation  

ix 


CONTENTS 

CHAPTER  PAGE 

Xir.     General  and  Local  Anesthesia 126 

Local  Anesthesia 126 

General  Anesthesia    127 

Local  Analgesia    137 

XIII.     Plastic   Surgery    144 

Dermoplasty '. 144 

^Method  of  Transfer 144 

Jumping 146 

The  Indian  Method 147 

The  Tagliacotian  Method  147 

EpideiTDal  Transplantation  —     »• — 

Riverdin   Method    148 

Thiersch's   Method    150 

Wolfe-Krause   Method    151 

PART  II 

Infections  of  Wounds  and  Surgical  Infectious  Diseases 

I.     General  Considerations  Regarding  Wound  Infections 157 

General    toxic    infection 157 

II.     The  Local  Disturbances  in  Wound  Infection 160 

III.  The  General  Disturbances  in  Wound  Infection 170 

The  Side  Chain  Theory  of  Ehrlich 176 

IV.  Hvpei'susceptibility    and    Anaphylaxis 182 

V.     Fever ". 186 

VI.     Pyogenic  Microorganisms , 191 

Staphylococci 191 

Streptococci 197 

Diplococcus  Pneumoniae 204 

Micrococcus  Tetragenus 208 

Diplococus  Gonorrhea  209 

Bacillus  Pyocyaneus 211 

Bacillus  Coli  Communis 214 

Bacillus   Typhosus    217 

VII.     Examination  of  Blood  and  Wound  Secretions,  etc.,  in  con- 
nection with  Surgical  Infections 225 

Examination  of  Blood 225 

Bacterial  Examinations  of  Material  from  Patients 231 

Examination  of  Exudate 231 

Spinal  Fluid   231 

Examination  of  Urine 232 

Examination   of   Feces 232 

Blood  Cultures   232 

The  Technic  of  Culturing  the  Blood 233 

Coagulation  of  the  Blood 233 

Cryoscopy 234 


CONTEXTS  xi 

CHAPTER 

PAGE 

VIII.     Entrance  Ports  of  Pyogenic  Infections 235 

IX.     Pyogenic  Infections  and  Tlieir  Treatment 239 

Tiie  Carrel-Dakin  Treatment 245 

X.     Pyogenic  Infections  of  the  Various  Tissues 255 

A.  Pyogenic    Infections    of    the    Skin    and    Subcutaneous 

Tissue 9-c 

Furuncle 9^5 

Carl)uncle 256 

The  Subcutaneous  Abscess   260 

Subcutaneous  Plilegmon   261 

Erysipelas 264 

Erysij^eloid o-j-q 

B.  Pyogenic  Infections  of  Mucous  Membranes 271 

C.  Pj'ogenie  Infections  of  Lymph  Vessels  and  Lym])hatic 


Glands 


276 


Acute  Lymphangitis 276 

Chronic    Lymphangitis    279 

Lymphadenitis ojg 

D.  Pj'ogenic  Infections  of  Blood   Vessels 283 


Arteritis 


283 


Phlebitis    284 

E.  Pyogenic  Infections  of  Bones 286 

Osteomyelitis 290 

F.  Pyogenic  Infections  of  Joints 309 

Serous  and  Serofibrinous  Synovitis 310 

Arthritis ^ll 

G.  Pyogenic  Infections  of  Tendon  Sheaths  and  Bursae.  .  .  319 
,  H.  Pyogenic  Infections  of  Muscles  and  Subfascial  and  In- 
termuscular Plilegmon 323 

Myositis .* 303 

Subfascial  and  Intermuscular  PhlegTiions 325 

I.    Pyogenic  Infections  of  Serous  Cavities  and  the  Various 

Organs 326 

XI.     General    Pyogenic    Infections 33O 

A.  Pyogenic    General   Infections   Avith    Metastases    (Meta- 
static Infection)    333 

Pyogenic    General    Infection    without    Metastases     (Xon- 

metastatic  Infection)    333 

XII.     The  Putrefactive  Infections 342 

Putrefactive  Wound  Infection  and  General  Infection...  342 

Allied  Processes   352 

Gas   Phlegmon    359 

Malignant   Edema    359 

Xoma  —  Cancrum  Oris  —  Gangrene  of  the  Cheek 352 

Hospital  Gangrene 355 

XIII.     Poisoned  Wounds 353 


Xll 


CONTENTS 


CHAPTER  Cine) 

XIV.    Rabies,  Lyssa,  Hydrophobia ^o- 

XV.     Tetanus og^ 

XVI.     Diphtheria „q. 

Diphtheria  of  Mucous  Membrane fo^ 

Diphtheria  of  the   Skin ^°^ 

XVII.     Anthrax ggg 

XVIII.     Glanders-Malleus ^^^ 

XIX.     Actinomycosis ^^2 

XX.     Madura  Foot    ^-j^g 

XXT.     Blastomycosis ^-j^'g 

XXII.     Sporothrichosis ^^^ 

XXIII.     Tuberculosis "  '  "  ,-■  ^ 

The  Bacillus   Tuberculosis ^^, 

Mode  of  Infection   ^^^ 

Tissue  Changes   ^^^ 

Local   Surgical    Tuberculosis 

A.  Tuberculosis  of  the  Skin 

B.  Tuberculosis  of  Sul)cutaneous  Tissue ^^^ 

C.  Tuberculosis  of  Muscles 

D    Tuberculosis  of  the  Mucous  Membranes ^*^ 

E.  Tuberculosis  of  Lymph  Vessels  and  Nodes ^do 

F.  Tuberculosis   of   Bones ^^^ 

G.  Tuberculosis  of  Joints •  •  • 

H    Tuberculosis  of  Tendon  Sheaths  and  Bursae.^ 4^9 

I     Tuberculosis  of  Serous  Cavities  and  Internal  Organs.  471 

General  Treatment  in  Local  Tuberculosis ^'- 

Acute  General  Miliary  Tuberculosis 4^^ 

XXIV.     Leprosy • ^gQ 

Leprosy  of  the  Skin ^ 

Leprosy  of  the  Nerves ^^^ 

XXV.  Syphilis .go 

A.  Svphilis  of  the  Skm " 

B.  Svphilis  of  :\Iucous  Membranes |^^ 

C.  Svphilis  of  Muscles r  ' y  l,' ' ' W^' 'a 

D.  Syphilis   of   the   Lymph   Vessels   and   of   the   Blood  ^^^ 

Vessels ^gg 

E.  Eyphilis  of  Bone ,^„ 

F.  Svphilis  of  Joints ' 

G.  Syphilis  of  Tendon  Sheaths  and  Bursae -^JJ" 

H.  Visceral  Syphilis    .. ' 

The  General  Treatment  of  Syphilis ^^^ 

Mercury ^-^-^ 

Arsenic 5-j^3 

XXVI.  Scleroma 5^.5 

XXVII.     Botryomycosis 


.   CONTENTS  xiii 

PART  III 

Necrosis 

CHAPTER  PAGE 

I.     Xeciosis  —  General    Considerations    519 

II.     Necrosis  Due  to  Trauma 522 

The  Direct  Result  of  Trauma,  and  Foilowinii-  Injuries  of 

Blood   Vessels    522 

III.  Necrosis  Due  to  Pressure,  Constriction,  Strangulation  and 

Torsion 526 

IV.  Necrosis  from  Thennal  and  Chemical  Causes 529 

V.     Necrosis  from  Embolism  and  Thrombosis 531 

VI.     Necrosis  Due  to  Chronic  Diseases  of  Blood  Vessels 534 

VII.     Necrosis  of  Neuropathic  Origin 546 

PART  IV 

IXJURIES  OF  THE  SOFT  PaRTS,   BoXES  AND  JoiXTS  AND  ThEIR 

Treatment 

I.     Injuries 553 

Mechanical  Injuries   553 

II.     Mechanical  Injuries  of  the  Different  Tissues 556 

Injuries  of  the  Skin,  Subcutaneous  Tissues  .and  Mucous 

^Membranes 556 

Injuries  of  Fascia  and  Muscle 562 

Injuries  of  Tendons    565 

Injuries  of  Peripheral  Nerves 573 

Injuries  of  Blood  Vessels 582 

Injui'ies  of  Lymphatic  Vessels 591 

Injuries  of  Joints 592 

III.  Dislocations 599 

Open  Injuries  of  Joints . . .  .- 636 

IV.  Injuries   to    the   Osseous   System 638 

Subcutaneous  Injuries  of  Bones  and   Cartilages 638 

Fractures 639 

Varieties 639 

Forms   of   Fracture .  .^ 640 

Diagnosis    644 

Open  Injuries  of  Bone  and  Cartilage 665 

V.     Sjiecial    Fractures    670 

Fractures  of  the  Bones  of  the  Face 670 

Fractures  and  Dislocations  of  the  Vertebral  Column 672 

Fractures  of  the  Vertebral  Column 672 

Fractures  of  the  Bodies  of  the  Vertebrae 672 

Symptoms 673 

Fi-actures  of  tlie  Vertebral  Arches  of  the  Processes 676 


xiv  CONTENTS 

CHAPTER  PAGE 

V.     Dislocations    of    the    Vertebrae 679 

Cervical    Luxations    679 

Dislocations  of  the  Dorsal  Vertebrae 683 

Lumbar  Luxations   683 

Fracture  Dislocations  of  the  Vertel)rae 684 

Fractures  of  the  Thorax 685 

Fractures  of   the   Ribs 685 

Fractures  of  the  Costal  Cartilages 687 

Fractures    of   the    Sternum 688 

Fractures  of  the  Upper  Extremity 689 

Fractures  of  the  Clavicle 689 

Fractures  of  the  Scapula 691 

Fractures  of  the  Humerus 692 

Fracture  of  the  Anatomical  Neck 692 

Fracture  of  the   Surgical  Neck 694 

Transtubercular  Fracture   701 

Traumatic  Epipliyseal  Separation 701 

Isolated  Fracture  of  the  Major  and  Minor  Tubercules.  702 

Fractures  of  the  Diaphysis  of  the  Humerus 703 

Fractures  at  the  Lower  End  of  the  Humerus 704 

Fractures  of  the  Forearm 714 

Fracture  of  the  Ulna   716 

Fracture  of  the  Coronoid  Process 717 

Fracture  of  the  Radius 720 

Fracture  of  the  Lower  Epiphysis  of  the  Radius  (Colles' 

fracture) ". 722 

Fractures  of  the  Hand  and  Fingers 728 

Fractures  of  the  Metacarpal  Bones 728 

Fracture  of  the  Pelvis 729 

Fractures  of  the  Femur 732 

Incomplete  Fractures  of  the  Neck  of  the  Femur  (Infrac- 
tion)     738 

Epiphyseal  Separation  at  the  Upper  end  of  tlie  Femur.  .  744 

Fractures  of  the  Femur  in  the  region  of  the  Trochanter.  744 

Isolated  Fracture  of  the  Trochanter  Major 744 

Fracture   of   the   Trochanter   Minor 744 

Fractures  of  the   Shaft   of  the   Femur  below   the   Tro- 
chanters    744 

Supracondyloid  Fractures    751 

Fractures  of  the  Patella 754 

Additional  Intra-Articular  Injuries  of  the  Knee  Joint.  .  .  .  760 

Isolated  Fractures  of  the  Upper  End  of  the  Tibia 761 

Isolated   Fractures  of  the  Capitulum  Fibulae 764 

Fractures  of  the  Leg  at  its  Middle 764 

Fractures  of  the  Leg  at  its  Lower  End 768 

Supra  Malleolar  Fracture  of  Both  Bones  of  the  Leg. . . .  769 


CONTEXTS  XV 

CHAPTER  PAGE 

Fractures  of  the  Malleoli 769 

Epiphyseal  Separation  at  the  Lower  End  of  the  Bones 

of   the   Leg    774 

Isolated  Fractures  of  the  Tibia  and  the  Fil)ula 775 

Fractures  of  the  Foot 775 

Fracture  of  the  Tuberosit,y  of  the  Calcaneuin 777 

Fracture  of  the  Sustentaculum  Tali 778 

Fracture   of   the   Inframmalleolar   Proces 778 

Fracture  of  Other  Bones  of  the  Foot 778 

Fractures  of  the  Metatarsal  Bones 779 

VI.     Operations  on  Bones  and  Joints 781 

Operations   on   Bones 781 

Osteoclasis 788 

Operative   Treatment  of  Recent   Fractures 788 

The  Operative  Treatment  of  L^united  Fractures 806 

Osteotomy 808 

Operations  on   Joints 810 

Arthrocentesis 811 

Arthrotomy 812 

Temporomaxillary   Joint    812 

The  Shoulder  Joint 815 

The  Elbow  Joint 820 

Wrist   Joint    827 

The   Hip   Joint    833 

Arthroplasty 838 

Arthrodesis 840 

The  Knee  Joint   841 

The  Ankle  Joint    852 

VIL     Amputations 861 

Amputation  of  the  Fingers 864 

Amputation  at  the  "Wrist 869 

Amputation  through  the  Foreai-m 874 

Amputation  at  the  Elbow 879 

Amputation   at   the    Shoulder 881 

Amputation  of  the  Toes 888 

Amputation  at  the  Ankle 888 

Chopart's   Amputation    890 

Amputations  through   the   Leg 894 

Amputations  at  the  Knee 898 

Amputations  through  the  Thigh 900 

Amputations  at  the  Hip 903 

VIII.     Gunshot  Wounds   908 

Wounds  Produced  by  Rifle  Bullets 908 

Wounds  of  the  Skin 912 

Wounds  of  Blood  Vessels 913 

Wounds  of  Peripheral  Nerves 913 


XVI 


CONTENTS 

CHAPTER  PAGE 

Wounds  of  Bones 913 

AVouuds  of  Joints   910 

AVounds  of  Organs  and  Cavities 91G 

Wounds  Caused  by  Artillery  Projectiles 917 

Treatment 919 

IX.     Chemical   Injuries    921 

X,     Thermal    Injuries     924 

Freezing' 924 

General  Fi-eezing    924 

Local    Freezing     925 

Burns .^ 929 

First  Degree  Burn    929 

Second  Degree  Burn   929 

Third  Degree  Burn  931 

X-Ray  Burns    936 

Electric   Burns    936 

Lightning  Stroke    936 

Sunstroke   and   Heat  Stroke 939 

XL     General  Effects  of  Injurv 942 

Collapse 942 

Syncope 943 

Shock 943 

XII.     Delirium   Tremens    947 

XIII.  Fat   Embolism    949 

XIV,  Traumatic  Diabetes   951 


PART  V 

Surgical  Diseases  Other  Than  Infections  and  Tumors 

I.     Surgical  Diseases  of  the  Skin 955 

Congenital   Malformations  of  tlie   Skin 955 

Eczema 955 

Edema  of  the  Skin  and  Mucous  Membranes 957 

Edema  of  Mucous  Meml)ranes 959 

Elephantiasis  960 

Rhinophyma 965 

II.     Diseases  of  Muscles  and  Tendons 967 

Congenital  IMuscular  Defects 967 

Atrophy  of  IMuscles 967 

Thickening,  Ganglion,  and  Ossification  of  Tendons 969 

III.  Diseases  of  Tendon  Sheaths  and  Bursae 971 

Synovitis 971 

Bursitis   .   .  ". 972 

IV.  Diseases  of  the  Blood  and  Lymph  Vessels 975 

Arteriosclerosis,   Atherosclerosis    975 


CONTENTS  xvii 

CHAPTER  PAGE 

Aneurisms 976 

Plilel)ec-tases,    Varices    994 

Tlirouil)u.-?is    and    Embolism    999 

Lympliangieetasis 1004 

V.     The  Ligature  of  Arteries  in  their  Continuity 1007 

Ligature  of  the  Abdominal  Aorta 1009 

Ligature  of  the  Iliac  Ax'teries 1010 

Ligation  of  the  Femoral  Arteries 1013 

Ligation  of  the  Tibial  Arteries 1016 

Ligature  of  tlie'  Innominate  Artery 1017 

Ligation  of  the  Subclavian  Arteries 1023 

Ligation  of  the  Carotid  Arteries 1027 

Ligation  of  the  Lingual  Artery 1029 

Ligation  of  the  Axillary  Artery 1030 

VI.     Diseases  of  Peripheran  Nerves. 1032 

Neuralgia 1032 

Neuritis   1036 

VII.     Diseases  of  Joints   1039 

Luxations  and   Subluxations    1039 

Contractures  and   Ankylosis    1040 

Special   Diseases  of  Joints 1049 

Sj'novitis  Chronica   Serosa-    1049 

Hydrops   Articularis   Chronicus    1049 

Hydrarthrosis 1049 

Chronic  Articular  Rheumatism   1050 

Arthritis,   Osteo-artlirisis   1053 

Chronica   Deformans-    1053 

Neuropathic  Arthritis    1057 

Hysterical    Joint    (Brodie's   Joint)     1059 

xVrticulav  Cout.     Arthritis  Urica    1061 

Joint   Diseases   in    Hemophilia    1063 

Ganglion 1065 

VIII.     Diseases  of  Bones   1069 

Congenital  Defects  in  Skeletal  Development 1069 

Atrophy  of  Bone   1070 

Hypertrophy  of   Bone    1072 

Rachitis,    or   Rickets    1074 

Scorbutus  —  Barbow's  Disease    1081 

Osteomalacia 1082 

Paget's    Disease    1084 

ilother-of-Pearl  —  "Workers'   Bone   Disease 1086 


xviu 


CONTENTS 


PART  VI 


I. 

II. 
III. 
IV. 

V. 
IV. 


VII. 

VIII. 

IX. 

X. 


XL 


XII. 

XIII. 
XIV. 

XY. 
XVI. 


XVII. 


Tumors 

PAGE 

Definition    and    Classification 1091 

Etiology  of  Tumors    1094 

Foi-m,  Growth,  and  Clinical  Significance  of  Tumors 1102 

The  Diagnosis  of  Tumors  in  General 1106 

The  Treatment  of  Tumors  in  General 1112 

The  Special  Tumors   1119 

Connective  Tissue  Tumors   1119 

Fibromata 1119 

Lipomata 1134 

Chondromata 1141 

Osteomata    1148 

Angiomata 1158 

Hemangiomata 1158 

Lymphangiomata   1167 

Sarcomata   1172 

Connective  Tissue   Sarcomata    1177 

Giant  Cell  Sarcomata   1178 

Chondrosarcomata 1183 

Osteosarcomata 1184 

Sarcomata  Composed  of  Cells  Resembling  Lymph  Cor- 
puscles    1191 

Multiple   Myelomata    1196 

Chloromata 1196 

Sarcomata     Originating     from   Mucous     Membranes  — 

Myxomata,  Myxsarcomata    1197 

Melanomata 1200 

Tumors    Composed    of   Muscle 1212 

Leiomyomata   1212 

Rhabdomyomata 1216 

Tumors  Composed  of  Nerve  Elements 1220 

Neuromata,   Ganglioneuromata    1220 

Gliomata 1222 

Tumors  Developing  from  Epithelium 1226 

Fibro-Epithelial    Tumors    1226 

Papillomata .  1226 

Adenomata 1230 

Epithelial  Cysts   1237 

Cholesteatomata 1242 

Adamantinomata  and  Follicular  Cysts  of  the  Jaws 1244 

Carcinomata   1253 

Carcinomata  of  the  Skin 1263 

Carcinomata  of  Mucous  Membranes 1273 

Carcinoma  of  Glandular  Organs  1280 

The  Clinical  Coui'se  of  Carcinoma 1282 


CONTENTS  xix 


XA'III.     Malisnant   Chorionic  Epithelioma    1285 

XIX.     Endothelial    Tumors    1287 

Endotheliomata    1287 

Hemangio-Endotheliomata 1289 

Peritheliomata 1289 

Dura-Endotheliomata 1290 

Cylindromata 1291 

XX.     Mixed"^  Tumors 1294 

Simple  Mixed  Tumors 1294 

Mixed  Tumors  of  the  Salivary  Glands 1295 

Mixed  Tumors  of  the  Breast/. 1298 

Mixed  Tumors  of  the  Genito  Urinary  System 1299 

XXL     Teratoid    Tumors    ".  .  . 1302 

Complicated  Dermoid  Cysts  of  the   Ovaiies  and   Testicles 

—  AYilms'  Cystic  Embryomata   1302 

Teratoid  Mixed  Tumors   1305 

XXII.     Teratomata 1308 


PART  VII 

Cysts 

(Excluding  Cjjsiic  Tumors) 

T.     Cysts  Other  Than  Cystic  Tumors 1313 

Exudation,  or  Extravastation  Cysts 1313 

Liquefaction    Cysts    1314 

Retention   Cysts   1314 

Parasitic    Cysts    1320 

Echinococcic  Cysts  1320 


PART  I 
"WOUNDS 


CHAPTER   I 
WOUNDS 

GENERAL  CONSIDERATIONS 

The  conservation  of  human  energy,  the  prolongation  of  life,  and  its 
maintenance  under  adverse  conditions  must  rest  upon  a  study  of  the 
modifications  which  occur  in  the  physiological  processes  within  the 
body,  when  these  are  disturbed  by  the  occurrence  of  pathological 
conditions.  For  this  purpose  it  is  not  necessary  to  discover  the 
so-called  principle  of  life.  The  behavior  of  living  organisms  under 
normal  or  pathological  conditions  and  the  changes  which  take  place 
in  the  body  in  the  ceaseless  contest  between  opposing  forces  may  be 
more  or  less  effectually  studied  without  "throwing  down  the  gauntlet 
to  the  great  Architect  of  the  universe"  in  a  futile  attempt  to  classify 
the  phenomena  of  disease  in  glittering  generalities. 

Life,  as  the  surgeon  understands  it,  is  an  exceedingly  complex 
manifestation,  and  is  maintained  as  the  result  of  certain  forces  which 
the  bod}'  marshals  against  the  invasion  of  affliction,  and  which  may  be 
designated  as  resistance.  When  the  ability  to  resist  is  at  an  end, 
death  occurs. 

Not  until  consistent  effort  was  made  accurately  to  standardize  the 
processes  which  take  place  in  the  body  when  it  is  subjected  to  disease- 
producing  factors,  be  these  the  outcome  of  bacterial  invasion  of  the 
blood,  as  in  bacteremia,  the  presence  in  the  blood  of  toxins  (toxemia), 
the  circulation  of  faulty  secretion  (thyroidism),  or  of  the  accumula- 
tion of  excretions  (uremia),  was  any  rational  conception  of  disease 
possible,  nor  indeed  was  the  employment  of  any  measures  of  relief 
entitled  to  serious  consideration. 

That  bacteria  (infection)  play  a  most  important  part  in  the  produc- 
tion of  disease  is  no  longer  to  be  doubted. 

If  the  work  in  the  laboratories  is  not  built  upon  fallacious  concep- 
tions of  the  physiological,  pathological  and  chemical  processes  which 
take  place  in  the  body,  then  the  possibilities,  with  respect  to  combating 
affliction,  lie  along  the  lines  of  biochemistry  and  chemicotherapy. 

3 


4  WOUNDS 

It  is  true  that  at  this  writing  biochemistry  holds  rank  over  chemico- 
therapy.  Remarkable  as  the  results  are  that  follow  the  use  of  anti- 
toxins, bacterins,  etc.,  they  present  a  no  more  alluring  condition  of 
affairs  than  the  recent  product  of  chemico-therapy  —  the  use  of 
arsenic  in  syphilis. 

Just  as  it  would  seem  proved  that  the  body  marshals  its  forces 
against  the  invasion  of  bacteria  by  the  development  of  antibodies, 
and  by  an  increase  in  the  corpuscular  elements  of  the  blood,  so  do  the 
tissues  concern  themselves  with  the  problem  of  repair  when  injury 
occurs. 

When  any  part,  organ  or  tissue  of  the  body  is  subjected  to  trauma, 
genesis  of  cellular  elements  takes  place  at  once.  This  is  called  regen- 
eration. When  bacteria  invade  the  tissues  of  the  body  practically 
the  same  changes  take  place,  and  this  is  also  called  regeneration. 

In  trauma  (per  se)  the  process  is  a  simple  one.  When  infection 
occurs  the  regeneration  is  never  as  complete  as  obtains  with  trauma, 
that  is  to  say,  degeneration  of  tissues  may  be  the  outcome  of  trauma 
and  regeneration  soon  take  place;  when,  however,  infection  occurs 
the  local  focus  may  extend  and  cause  degeneration  not  only  at  the 
site  of  the  primary  port  of  entrance  but  may  successively  invade 
contiguous  or  distant  areas  of  the  body,  and  thus  stand  in  a  causative 
relationship  to  a  fatal  outcome.  The  latter  condition  of  affairs  may 
be  well  illustrated  in  syphilis.  In  a  given  case  the  blood  itself  may 
not  show  any  evidence  of  this  dread  disease  and  indeed  may  not 
contain  any  pernicious  elements;  however,  a  gumma  situated  in  a 
distal  phalanx  may  be  the  residence  of  numerous  spirochetae  which 
may  suddenly  invade  the  circulating  tluid,  be  deposited  in  the  intima 
of  the  middle  cerebral  artery,  and  a  fatal  cerebral  hemorrhage  be  the 
result.  With  uncomplicated  trauma  this  is  not  the  case.  Here 
regeneration  takes  place,  and  the  ultimate  outcome  is  quite  in  accord 
with  the  degree  and  character  of  trauma  that  destroyed  the  tissue 
at  first. 

In  1901  Senn  stated:  "Regeneration  includes  a  multitude  of  pro- 
cesses which  are  intended  to  repair  the  normal  physiological  waste 
of  the  tissues  in  the  living  body,  or  to  restore  tissue  lost  by  injury  or 
disease.  In  the  human  body  normal  regeneration  or  repair  of  tissues 
is  a  physiological  process  which  is  essential  for  the  maintenance  of 
the  anatomical  perfection  and  functional  activity  of  the  different 
tissues  and  organs.  In  a  condition  of  perfect  health  in  the  full- 
grown  body,  the  normal  waste  incident  to  the  increasing  activity  of 


WOUNDS  5 

the  tissues  is  balanced  by  this  reparative  process,  while  during  the 
development  of  the  body  an  excess  of  material  is  added,  upon  which 
depends  the  increase  of  tissue  which  constitutes  growth.  If  cell 
destruction  is  in  excess  of  cell  reproduction  atrophy  is  the  inevitable 
result,  and  if  the  function  of  regeneration  is  completely  suspended 
death  must  necessarily^  ensue,  the  blood  being  the  first  tissue  to  undergo 
extreme  atrophic  changes,  soon  to  be  followed  by  similar  changes  in 
all  the  tissues,  resulting  in  diminution  of  function  proportionate  to 
the  degree  of  atrophy,  and  finally  death  from  marasmus. 

"Studied  from  a  surgical  aspect,  regeneration  includes  the  process 
observed  in  the  healing  of  w^ounds  produced  by  trauma,  and  the  com- 
plete or  partial  restoration  of  parts  damaged  or  destroyed  by  the 
action  of  chemical  substances,  extremes  of  cold  and  heat  and  the 
various  destructive  inflammatory  processes  caused  by  the  presence  of 
specific  microorganisms.  Kegeneration  and  inflammation  are  distinct 
conditions  which  should  no  longer  be  confounded  or  considered  from 
the  same  etiological  and  pathological  standpoint.  An  ideal  regenera- 
tion takes  place  without  inflammation,  provided  the  seat  of  injury  or 
tissue  destruction  remains  aseptic,  that  is,  free  from  pathogenic 
microbes.  On  the  other  hand,  a  regenerative  process  within  or  around 
an  inflammatory  focus  can  be  established  only  in  tissues  in  which  the 
cause  that  has  produced  the  inflammation  has  not  been  sufficiently 
intense  to  destroy  the  protoplasm  of  the  cells.  Under  these  circum- 
stances the  reparatory  process  is  initiated  at  a  time  when  the  cause 
that  has  given  rise  to  the  inflammation  has  ceased  to  be  active,  or  in 
tissues  not  deprived  of  their  vegetative  power  by  its  action.  In  a 
circumscribed,  suppurative  inflammation  the  cells  exposed  to  the 
direct  action  of  the  pus  microbes  and  their  products  are  destroyed, 
and  the  process  of  repair  starts  in  the  abscess  walls  and  their  imme- 
diate vicinity,  from  tissues  that  have  retained  their  power  of  cell 
proliferation.  Any  organ,  the  seat  of  a  tuberculous  infection,  in 
which  the  parasitic  cause  is  not  sufficiently  intense  to  destroy  the 
vitality  of  the  cells,  retains  its  normal  structure  and  function  by  virtue 
of  this  intrinsic  power  of  regeneration  of  its  cells.  All  reparative 
processes  consist  of  homologous  cell  development,  and  the  new  tissue 
resembles  anatomicallj'  and  physiologically  the  fixed  cells  from  which 
it  is  produced.  The  legitimate  succession  of  cells  is  now  a  well  estab- 
lished law  in  pathology-  as  well  as  in  embryology,  and  according  to 
this,  tissue  is  never  produced  by  substitution  of  function.  In  accord 
with  this  histogenic   law,   each   cell   element   possesses   an    intrinsic 


6  WOUNDS 

vegetative  power  from  the  earliest  embryonal  development  throughout 
life,  which,  in  case  of  loss  of  tissue  by  injury  or  disease,  enables  it  to 
produce  its  own  kind,  and  never  any  other  materially  different  histo- 
logical structure.  In  conformity  with  this  general  law  of  tissue 
production,  an  injury  or  defect  of  a  nerve  fiber  is  repaired  by  pro- 
liferation from  preexisting  cells  w^hich  compose  this  structure, 
epithelial  cells  are  produced  only  by  epithelial  cells,  new  vessels  are 
formed  from  cells  which  exist  in  a  normal  vessel  w^all,  etc." 

The  general  principles  laid  down  in  these  tersely  put  sentences  are 
as  true  to-day  as  they  were  then,  and  with  the  exception  perhaps  of 
difference  of  nomenclature,  may  be  regarded  as  authoritative  in  this 
connection. 

The  phenomena  attendant  upon  the  repair  of  tissues  which  have 
been  subjected  to  trauma  present  the  simplest  problem  confronting 
the  surgeon. 

Repair  of  a  wound  is  purely  a  regenerative  process,  attended  with 
cellular  activity  proportionate  to  the  extent  of  trauma,  and  is  not 
productive  .of  activities  on  the  part  of  the  body  tissues,  in  their  effort 
to  overcome  the  changes  incident  to  infection. 

Infective  processes  give  rise  to  cellular  activity  and  biochemical 
changes,  the  character  of  -which  is  modified  in  accordance  with  the 
virulence  of  the  invading  infection,  and  thus  presents  problems  of 
a  complicated  nature. 

Expressed  concisely,  one  may  say  that  the  essential  difference 
between  regeneration  devoid  of  complicating  infection,  and  the  pro- 
cesses accompanying  the  invasion  of  pathogenic  bacteria  is,  that  in 
the  solution  of  continuity  by  trauma  the  tissues  are  concerned  only  in 
replacing  themselves  to  the  extent  of  the  injury,  whilst,  when  infection 
occurs,  the  tissues  (which  include  the  blood)  are  called  upon  to  com- 
bat the  progressive  destruction  incident  to  the  process,  and  the  body 
as  a  whole  is  called  upon  to  render  inert,  to  neutralize,  or  to  eliminate 
the  actual  toxic  substances  which  develop  as  the  outcome  of  the 
infection. 

In  this  wa}^  the  reader  may  be  impressed  with  the  necessity  of 
directing  measures  for  the  avoidance  of  complications  which  may  arise 
in  conjunction  with  accidental  trauma  and  make  proper  endeavor  that 
surgical  efforts  for  relief  of  affliction  shall  not  be  rendered  futile  by 
processes  which  are  the  outcome  of  infection. 

It  must  be  clearly  understood  that  surgical  technic  simply  places 
a  wound  in  a  condition  permitting  the  natural  process  of  repair,  and 


WOUNDS  7 

that  the  technic  applicable  to  accomplish  this  end  in  a  given  instance 
must  vary  with  the  character  of  wound  under  consideration,  and 
for  this  reason  it  would  seem  proper  to  study  at  first  what  takes  place 
in  the  tissues  after  simple  trauma,  so  that  there  might  be  an  under- 
standing of  the  rationale  of  the  surgeon's  technic,  and  how  this  is  to 
be  exercised  so  that  repair  may  take  place  under  the  most  favorable 
conditions. 

HEALING  OF  WOUNDS 

Only  a  few  tissues,  to  be  taken  up  later,  reproduce  cellular  elements 
which  in  all  essential  characteristics  are  similar  to  those  destroyed  by 
trauma.  Bone  cells  reproduce  bone  cells,  epithelial  cells  produce 
epithelial  cells;  however,  the  cells  of  highly  organized  tissues,  such  as 
nerve  centers,  the  liver  cells,  muscle  fiber  and  the  like,  when  once 
destroyed  are  not  reproduced  and  may  be  regarded  as  lost.  Repair 
in  these  latter  instances  takes  place  by  the  production  of  fibrous  tissue 
which  in  most  instances  does  not  interfere  materially  with  the  function 
of  the  part  damaged  by  the  trauma ;  that  is  to  say,  a  considerable 
portion  of  a  highly"  functionating  organ  may  be  destroyed  and  repair 
with  scar  tissue  take  place,  and  yet  sufficient  functionating  cellular 
elements  may  remain  intact  so  that  no  perceptible  lessening  of  function 
occurs,  though  this  fortunate  outcome  is  of  course  dependent  upon 
the  extent  of  the  injury  and  the  excess  of  functionating  elements  with 
which  each  organ  is  endowed  by  nature. 

It  is  the  general  process  of  repair,  as  it  takes  place  in  the  body 
generally,  that  is  taken  up  in  the  immediately  succeeding  portion  of 
this  work. 

It  will  be  seen  farther  on  that  wounds  are  described  with  respect  to 
certain  characteristics,  as  for  instance  method  of  production,  whether 
they  are  the  result  of  cutting  or  tearing  forces  and  that  the  healing 
of  wounds  varies  in  certain  regards ;  however,  the  presentation  of  this 
subject  in  a  more  or  less  ritualistic  manner  as  must  of  necessity  obtain 
in  a  textbook,  is  endowed  with  an  element  of  simplicity  when  it  is 
stated  at  this  time  that  the  process  of  repair  is  similar  in  all  instances, 
the  variance  of  the  clinical  picture  being  due  to  the  degree  of  cellular 
activity.  Indeed  the  same  may  be  said,  not  alone  irrespective  of  the 
character  of  injury,  but  also  as  to  whether  a  healing  by  so-called  first 
intention  be  achieved  or  the  trauma  be  complicated  by  infection. 

Clinically,  wounds  whose  surfaces  lie  in  apposition,,  heal  by  primary 
union,  wounds  whose  surfaces  are  separated,  wounds  that  are  infected, 
or  wounds  involving  loss  of  substance  heal  by  secondary  union. 


8  WOUNDS 

In  some  instances  secondary  healing  may  be  accelerated  by  apposi- 
tion of  wound  surfaces  in  which  the  process  of  repair  is  dominantly 
established,  and  this  is  at  times  called  healing  by  third  intention,  an 
unnecessary  addition  to  the  terminolog}^  of  the  subject. 

Primary  "Union. —  The  Sanatio  per  primam  intentionem  of  Galen 
occurs  in  a  week.  This  phenomenon,  unattended  as  is  is  wath  gross 
changes,  has  led  to  the  belief  that  immediate  union,  i.  e.,  healing  with- 
out the  complicated  process  alluded  to  above,  may  take  place,  but  as 
a  matter  of  fact  in  this  class  of  injury  scar  tissue  alwaj'S  forms, 
although  it  is  microscopic  in  character.  Scar  tissue  is  the  inevitable 
sequel  of  all  wounds,  and  at  best  only  becomes  indiscernible  to  the 
naked  eye  hy  the  deposit  of  a  covering  of  horny  epithelium,  or  by 
being  hidden  in  the  folds  of  the  skin. 

Between  the  closely  apposed  surfaces  of  the  wound  there  is  deposited 
a  layer  of  fibrin  which  consists  of  the  debris  of  blood  cells,  lymph  and 
serum,  called  wound  secretion.     This  is  the  first  step  in  primarj^  union. 

The  w'ound  secretion  acts  as  a  mechanical  cement  holding  together 
the  wound  surfaces ;  it  takes  no  part  in  the  healing  process  but  fills 
the  inevitable  gaps  of  the  wounds  and  overflows  upon  the  surfaces  of 
the  contiguous  skin  forming  a  scab  that  ultimately  separates  leaving 
a  lesser  or  greater  linear  scar. 

The  regenerative  process  begins  simultaneously  with  the  formation 
of  wound  secretion.  In  response  to  the  irritation  of  trauma  the  capil- 
laries in  the  vicinity  of  the  wound  dilate,  and  together  with  the 
contiguous  blood  vessels  become  filled  with  blood  {regenerative  hyper- 
emia) ;  polynuclear  leukocytes  at  the  same  time  accumulate  along  the 
walls  of  the  blood  vessels. 

The  leukocytes  (phagocj'tes)  perform  an  important  office,  as  they 
absorb  the  destroyed  cells  by  the  production  of  ferments  which  are 
capable  of  dissolving  albumin,  and  also  produce  a  protective  sub- 
stance chemically  destructive  to  pathogenic  bacteria  which,  despite 
the  most  rigid  precautions,  prophylactic  or  antiseptic,  are  present  in 
all  wounds.  Beyond  this,  leukocj'tes,  by  virtue  of  the  motility  of  their 
protoplasm,  possess  a  truly  phagocytic  power,  being  capable  of  taking 
up  minute  particles  of  necrotic  tissue.  In  the  exercise  of  their  office 
many  leukocytes  are  destroyed,  though  these  are  soon  replaced  by 
others. 

Phagocytosis  is  not,  however,  limited  to  the  leukocj'tes,  indeed  cer- 
tain protoplasmic  tissue  cells  or  macrocytes  which  supplement  the 
work  of  the  leukocytes,  make  their  appearance  in  the  vessels  contigu- 


WOUNDS  9 

ous  to  the  wound,  taking  up  fat  globules  and  blood  pigment  in  great 
quantities,  together  with  the  deformed  and  destroyed  leukocytes,  until 
these  cellular  elements  become  engorged  globules  that  enter  the  lymph 
stream  and  are  lost  in  the  lymph  nodes. 


-jManmi'ift"'.  .1(5 


*^^?^S'l9ai»*ww~-        .^'■^^ann^' 


Fig.  1. —  Cells  Concerned  in  Healing. 

a,  h,  Blastomatomycetcs  (Eanvier)  ;  c,  vasculated  fatty  tissue  cells;  d,  e,  f,  g,  i, 
j>  P,  Q,  fibroblasts;  /*,  giant  cells;  A;,  I,  m,  n,  mitosis  in  connective  tissue  cells;  o, 
plasma  cells. 


Proliferation  of  tissue  cells  begms  simultaneouslj'  with  the  process 
just  described.  The  appearance  of  numerous  karj^okinetic  figures 
heralds  proliferation  of  the  vessel  endothelial  and  connective  tissue 


10 


WOUNDS 


cells.  At  the  same  time  large  irregularly  formed  cells  make  their 
appearance,  these  are  uni-,  bi-,  or  polynuclear  (the  last  called  giant 
cells).     These  cells,  called  fibroblasts  (Fig.  1),  originate  from  connec- 


Fig.  2. —  Healixg  of  a  Sutured  Incised  Wound  of  the  Skin  Six  Days  Old. 

(After  Ziegler.) 

a,  epidermis;  6,  corium;  c,  fibrinous  part  of  the  exudate;  d,  newly  formed 
epidermis  which  contains  numerous  karyokinetic  figures  and  epitlielial  processes, 
which  have  penetrated  the  exudate  beneath  it;  c,  karyokinetic  figures  in  the 
.epithelium  somewhat  removed  from  the  line  of  incision;  /,  germinal  tissue  de- 
veloping from  the  connective  tissue,  which  also  contains  proliferating  vessels ; 
g,  proliferating  germinal  tissue  with  leukocytes;  li,  groups  of  leukocytes  in  the 
inner  part  of  the  wound;  i,  fibroblasts  lying  in  the  exudate;  fc,  sebaceous  glands; 
I,  sweat  glands. 

tive  tissue,  proliferate  into  the  wound  area,  and  progressively  invade 
and  supplant  the  cement  fibrin  layer  already  described  (Fig.  2). 
The  wound  surfaces  are  now  held  in  apposition  by  a  mixture  of 


WOUNDS  11 

fibroblasts,  leukocytes,  lymphocytes  and  plasma  cells  together  with 
proliferating  blood  vessels,  which  is  called  emhryonic  tissue.  New 
blood  vessels  are  formed  by  the  budding  of  solid  arched  protoplasmic 
projections  which  arise  from  the  walls  of  capillaries,  coalesce,  and,  as 
the  outcome  of  liquefaction  of  their  central  portion,  become  patent 
carriere   of    the    circulating    fluid.     When    embryonic    tissue    has 

BECOME  VASCULARIZED  IN  THE  MANNER  STATED  IT  IS  CALLED  GRANULATION 
TISSUE. 

As  already  stated  this  process  occupies  approximately  seven  days 
of  time.  At  first  the  site  of  repair,  which,  after  healing,  is  called  a 
scar,  is  red  in  color  due  to  a  preponderance  of  new  blood  vessels; 
gradually  the  connective  tissue  development  predominates,  many  of 
the  blood  vessels  are  obliterated  and  the  scar  pales ;  later  on  much  of 
the  connective  tissue  is  absorbed,  while  that  remaining  takes  on  the 
characteristics  of  elastic  tissue,  so  that  in  some  instances  the  presence 
of  the  abnormality  may  be  only  determined  with  the  help  of  the  micro- 
scope. Only  after  years  is  there  left  a  smooth  white  surface  which  is 
recognizable  because  of  the  absence  of  pigment  and  papillary  cells 
(Marchand^). 

The  less  severe  the  trauma,  and  consequently  less  extensive  regen- 
erative hyperplasia,  the  less  manifest  will  be  the  ultimate  scarring. 

Secondary  Union. —  The  Sanatio  per  secunclam  intentionem  of  Galen 
is  characterized  hy  the  same  phenomena  and  the  same  cellular  changes 
described  while  discussing  primary  healing  (p.  8),  the  process  being 
only  greater  in  magnitude. 

Clinically,  secondary  healing  of  a  wound  is  differentiated  from 
primary  healing  by  the  appearance  in  the  former  of  a  red  granular 
tissue  called  granulation  tissue  that  covers  the  surfaces  of  wounds,  in 
which  primary  union  failed  to  occur  as  the  outcome  of  the  character 
of  trauma  standing  in  a  causative  relationship  to  the  injury  or  when 
infection  has  occurred. 

After  two  or  three  days  wounds  healing  by  secondary  union  are 
covered  with  a  mixture  of  blood  detritus  and  fibrinous  exudate,  which 
soon  undergoes  superficial  necrosis,  becomes  fluid  by  the  admixture 
of  leukocytes  and  serum  and  is  discharged,  varA'ing  in  character,  in 
accord  with  the  predominance  of  its  constituents,  from  serum  to  pus. 

Necrosis  of  the  exudate  and  a  serous  discharge  always  accompany 
secondary  healing;  the  admixture  of  sufficient  leukocytes  to  render 
purulent  the  discharge  signifies  infection.  It  is  conceivable  that 
moderate  infection  would  be  accompanied  b}-  a  seropurulent  discharge 


12  WOUNDS 

and  a  degree  of  hyperemia,  which  would  also  carry  out  an  accord  in 
this  connection. 

In  from  four  days  to  a  week  small  areas  of  granular  masses  appear 
upon  the  surfaces  of  the  wound;  these  are  called  granulations  and 
consist  of  proliferated  connective  tissue  cells.  Each  granulation 
receives  a  capillary  loop,  and  soon  the  entire  wound  is  filled  with 
granulation  tissue  in  which  the  blood  vessels  continue  to  bud  and 
coalesce.     As  proliferation  goes  on  the  fibrinous  exudate   and  the 


Fig.  3. —  Section  Through  the  Edge  op  a  Granulating  Incised  Wound  About 
Three  Weeks  Old  Surrounding  a  Fistula  Leading  to  an  Osteomyelitic 
Focus  in  the  Femur.     (After  Marchand.) 

c,  cutis;  /,  fat;   e,  e,  newly  formed  epidermis;   gr,  granulations;   g,  vessels  of 
the  granulations  ascending  from  the  cutis. 

necrotic  cellular  elements  are  entirely  displaced  and  the  wound  is 
filled  level  with  the  edges  of  the  skin,  with  healthy  granulation  tissue. 
At  this  time  repair  of  a  gaping  wound  may  be  accelerated  by 
approximation  of  healthy  granulating  surfaces.  As  the  granulations 
thus  apposed  readily  coalesce,  the  rest  of  the  process  is  similar  to 
healing  by  primary  intention,  an  occurrence,  the  rationale  of  which 
is  easily  understood  when  it  is  here  reiterated  that  the  process  of 

HEALING  IS,  HISTOLOGICALLY,   THE  SAME  IN  HEALING  BY  PRIMARY  OR  BY 
SECONDARY  INTENTION. 


WOUNDS  15 

When  healing  takes  place  in  the  manner  just  described,  it  is  called 
union  by  third  intention. 

While  the  wound  healing  by  second  intention  is  being  filled  with 
'healthy  granulation,  the  fluid  discharge  mechanically  cleanses  the 
surfaces  of  the  wound  and  exercises  what  germicidal  properties  it 
possesses  in  destroying  the  ever  present  microorganisms. 

In  the  deeper  laj'ers  the  connective  tissue  fibers  formed  by  the 
fibroblasts  lie  parallel  to  the  surface  of  the  wound.  More  super- 
ficially the  fibrils  arrange  themselves  perpendicularly',  climbing  up  as 
it  were,  together  with  the  budding  blood  vessels  (Figs.  3  and  4). 

In  the  more  superficial  portion  of  a  granulating  wound,  the  connec- 
tive tissue  is  not  as  dense  as  obtains  in  the  deeper  layers. 

Epidermizatio7i  begins  when  granulation  reaches  the  level  of  the 
skin.  The  new  epidermis  develops  by  proliferation  of  the  epithelial 
cells  from  the  skin  at  the  edges  of  the  wound,  appearing  as  a  thin, 
bluish  white  line  which  slowly  extends  across  the  wound  until  repair 
is  complete.  The  new  epithelium  at  times  invades  the  areas  between 
granulations,  forming  the  irregular  papillae  seen  on  recently  healed 
wounds.  The  small  epithelial  islands  sometimes  observed  upon  the 
surface  of  granulating  wounds  proliferate  from  portions  of  sweat 
glands  and  hair  follicles,  which  survived  the  effects  of  the  original 
destructive  force. 

When  epidermization  is  complete,  cicatrization  of  the  newly  formed 
connective  tissue  goes  on,  the  fibers  of  the  scar  tissue  shrink,  become 
more  dense  and  have  a  tendency  to  lessen  in  area;  this  leads,  not 
infrequenth',  to  deformations  such  as  ectropion,  hammer  toe  and 
disturbances  of  motility  of  joints,  etc. 

Scar  tissue  does  not  contain  nerve  fibers,  elastic  fibers,  nor 
the  various  glandular  elements  of  the  skin. 

As  time  goes  on  scars  become  pale  as  the  outcome  of  obliteration  of 
the  newly  formed  blood  vessels.  In  some  instances  connective  tissue 
instead  of  contracting  continues  to  proliferate,  forming  large  vascular 
protrusions  which  are  called  keloids  (Part  VI,  chap.  vi). 

Healing  Under  a  Scab. —  Clinically,  repair  under  a  scab  follows 
superficial  abrasions  and  injuries  of  the  skin  (after  removal  of  skin 
grafts  to  be  used  for  transplantation)  that  do  not  involve  the  entire 
thickness  of  the  skin.  This  so-called  scab  consists  of  dried  sero- 
fibrinous exudate  mixed  with  blood  detritus. 

As  a  matter  of  fact,  wounds  healing  by  primary  union  have  their 
narrow  linear  surface  covered  with  a  material  similar  to  that  just 


14 


WOUNDS 


Fig.  4. —  Section  of  Granulatiox  Tissue  Kemoted  from  an  Abscess  Membrane 
Surrounding  a  Suppurating  Focup  in  Bone. 

Superficial  layer. 


WOUNDS 


15 


described  (p.  13).  Indeed  at  all  times  the  edges  and  sometimes  the 
entire  surfaces  of  wounds  healing  by  second  intention  are  encrusted 
with  the  same  material  (Fig.  5). 

Injuries  healing  under  a  scab  are  soon  epidermatized,  the  new 
epidermis  proliferating  from  the  edges  of  the  wound  and  also  grow- 
ing from  insular  areas  of  the  malpighian  layer  of  the  skin  not  entirely 


.^  \ 


»  A 


es 


^     f 


^       <» 


-'^ 


Fig.  5. —  Margin  of  a  Skin  Defect  Following  the  Ee:moval  of  Epidermal 
Strips  for  Skin  Grafting.     (After  Marchand.) 

a,  newly  formed  epidermis  at  tlie  margins  of  the  wound;  6,  end  of  the  same 
which  projects  in  the  form  of  a  process  into  the  crust ;  c,  which  is  somewhat 
loosened;  d,  space  in  which  iodoform  crystals  lie;  e,  cutis;  /,  which  is  almost 
unchanged ;  g.  a  newly  formed  epidermal  growth  which  has  extended  downward 
in  the  form  of  a  round  process  between  the  connctive  tissue  bundles. 


destroyed  by  the  injury.     Much  the  same  process  takes  place  when 
liealing  occurs  beneath  a  thermal  bleb. 

When  a  wound  healing  by  second  intention  is  covered  by  a  scab, 
proliferation  of  epidermal  epithelial  cells  takes  place  from  the  rim 


16  WOUNDS 

of  the  wound,  finding  its  way  beneath  the  scab,  which  latter  spontane- 
ously exfoliates  when  repair  is  complete  (Marchand^). 

In  this  connection  it  is  interesting  to  note  that  when  epidermization 
progresses  under  the  protection  of  a  scab,  and  the  scab  is  forcibly 
removed  or  displaced  by  the  fluid  discharge  consequent  to  late  infec- 
tion, there  is  a  perceptible  delay  in  the  rate  of  epidermal  growth  as 
compared  with  what  obtained  when  the  scab  was  still  in  situ.  This  fact 
possesses  some  clinical  value ;  however,  healing  under  a  scab  is  advan- 
tageous ONLY  IN  THE  ABSENCE  OP  INFECTION,  AND  V^HEN  INFECTION 
OCCURS,  THE  PRESENCE  OF  THE  SCAB  DELAYS  HEALING  BECAUSE  OF  THE 
RETENTION  OF  PERNICIOUS  W^OUND  SECRETIONS. 

Unhealthy  Granulations. —  Granulation  tissue  presents  a  vary- 
ing appearance  according  to  whether  the  granulations  are  healthy  or 
unhealthy. 

Healthy  granulations  are  hard,  firm,  engorged  with  blood,  and  do 
not  readily  degenerate;  per  contra,  unhealthy  granulations  are  pale, 
spongy,  smooth,  and  frequently  are  covered  with  fibrinous  exudate 
that  readily  degenerates  and  is  taken  up  in  the  form  of  one  of  the 
constituents  of  the  wound  discharge. 

The  etiology  of  unhealthy  granulations  is  of  considerable  clinical 
importance,  and  may  be  divided  into  constitutional  and  local  causes. 

Patients  recovering  from  exhausting  diseases  or  afflicted  with  con- 
stitutional ailments,  such  as  lues,  tuberculosis  and  various  diatheses 
are  likely  to  make  sluggish  repair  of  wounds,  the  metabolic  material 
furnished  the  cellular  elements  concerned  in  healing  apparently  being 
insufficient  for  the  purpose;  this  manifesting  itself  in  the  appearance 
of  so-called  unhealthy  granulations  in  the  wound.  It  would  seem 
that  the  constitutional  causative  factor  in  these  cases  is  a  quasi 
negative  one. 

The  chief  local  cause  of  unhealthy  granulations  is  the  presence  of 
bacteria  in  the  wound,  though  this  manifestation  is  rare  in  acute 
conditions  (pyogenic  infections)  ;  on  the  other  hand,  the  persistent 
recurrence  of  exuberant  unhealthy  granulations  is  quite  indicative  of 
chronic  processes  (tuberculosis,  lues,  infection  with  communis  coli, 
etc.),  and  is  due  to  persistent  lavage  of  granulating  surfaces  with 
pernicious  fluid  secretions.  This  may  be  observed  in  fistulae,  cloacae, 
etc.,  a  class  of  cases  in  which  exuberant  granulations  protrude  beyond 
the  surface  of  the  contiguous  skin;  those,  however,  do  not  progress 
beyond  the  stage  of  fibroblastic  cell  formation  when  they  undergo 
necrosis  (Reinbach^). 


WOUNDS  17 

Chemical,  thermal  or  mechanical  destruction  of  unhealthy  granula- 
tions at  times  sufficiently  lessens  bacterial  flora  and  stimulates  to 
proliferation  the  deeper  lying  fibrous  tissue  so  that  healing  is 
accomplished. 

Wounds  covered  with  unhealthy  granulations  do  not  epidermatize 
for  the  reason  that  the  presence  of  the  exuberant,  spong}'  projections 
mechanically  interferes  with  the  progress  of  epithelial  growth,  also 
because  large  numbers  of  the  epithelial  cells  are  destroyed  by  the 
wound  secretion. 

At  this  time  it  would  seem  proper  to  state  that  the  necrosis  of 
UNHEALTHY  GRANULATIONS  differs  from  true  ulceration  in  that  the 
former  is  a  destruction  of  partially  formed  reparative  elements, 
while  ULCERATION  is  a  progressive  degeneration  of  healthy  tissue 
subjected  to  invasion  on  the  part  of  a  pathological  process.  The 
term  "pathological  process"  as  used  here  includes  trophoneurotic 
processes  as  well  as  those  of  a  chronic  infective  character  (tubercu- 
losis, lues,  etc.). 

Repair  of  highly  functionating  organs  also  takes  place  by  the  forma- 
tion of  connective  tissue.  It  has  been  held  that,  in  some  instances, 
functionating  cellular  elements  are  regenerated  after  complete  destruc- 
tion (nerves,  etc.).  If  this  happens,  the  regeneration  occurs  after 
the  connective  tissue  genesis  is  completed.  In  any  event  little  is  to  be 
expected  in  this  connection.  It  is  'probable  that  the  cells  of  the 
cerebrospinal  centers  do  not  regenerate. 

On  the  other  hand,  cartilage  and  bone  tissue  does  regenerate. 
Embryonic  cells,  springing  from  the  perichondrium,  periosteum  and 
bone  marrow,  replace  cellular  elements  destroj-ed  by  trauma  and 
disease  to  an  extent  that  renders  ph^'siologically  perfect  the  afflicted 
part. 

JJnion  of  serous  surfaces  in  gastro-intestinal  anastomoses  takes  place 
by  a  primary  fibrinous  cementing  and  is  ultimately  firmly  attained 
by  the  formation  of  a  connective  tissue  union,  similar  in  all  essential 
regards  to  scar  tissue  elsewhere  in  the  bod.v.  At  the  site  of  the  inner 
aspect  of  the  area  of  union  after  the  mucosa  has  healed,  the  epithelial 
cells  proliferate  in  much  the  same  manner  as  obtains  on  the  skin.  A 
few  glandular  structures  develop  beneath  the  new  epithelium.  In 
some  instances  a  moderate  amount  of  proliferation  of  unstriped 
muscular  fibers  also  takes  place  in  this  situation. 

Serous  surfaces  are  exceedingly  susceptible  to  trauma.  Relatively  slight 
injury  such  as  prolonged  exposure  to  the  air,  manipulation,  contact  with  gauze 


18  WOUNDS 

packing,  use  of  chemical  irritants,  etc.,  is  followed  by  a  startlingly  dispropor- 
tionate proliferation  of  cellular  elements,  which  leads  to  the  production  of 
connective  tissue  that  ultimately  forms  adhesions,  causing  serious  interference 
with  function. 

Repair  of  injured  and  deligated  blood  vessels  also  takes  place  by 
the  formation  of  connective  tissue,  the  process  varying  from  the  one 
already  described,  in  that,  in  this  situation  the  hudding  of  Uood 
vessels  precedes  the  genesis  of  connective  tissue.  The  new  blood  ves- 
sels chiefly  develop  from  the  vasa  vasorum,  but  are  in  part  furnished 
from  contiguous  capillaries. 

Blood  vessels  whose  intima  has  been  injured  obliterate  by  the  forma- 
tion of  blood  clot,  which  ultimately  undergoes  the  same  changes 
described  in  connection  with  healing  of  wounds  generally. 

Action  Upon  Foreign  Bodies. —  Grmiulation  tissue  dissolves,  expels 
or  encapsulates  foreign  hodies  and  establishes  a  connective  tissue  heal- 
ing with  transplanted  tissues;  in  each  instance  the  actual  cellular 
changes  are  the  same  as  obtain  in  the  healing  of  wounds.  The  irrita- 
tion of  foreign  bodies  causes  regenerative  inflammation  and  this  leads 
to  proliferation  of  fibrous  tissue.  Leukocytes  and  fibroblasts  gnaw 
their  way  into  absorbable  foreign  bodies  and  necrotic  tissue,  forming 
at  the  edges  of  the  material  thus  attacked  small  lacunae  which  are 
not  unlike  those  attendant  upon  the  absorption  of  bone. 

Catgut  and  the  fhrin  of  hematomata  are  rendered  fluid  by  the  action 
of  cellular  ferments  and  are  completely  absorbed.  The  areas  previ- 
ously occupied  by  these  foreign  substances  are  ultimately  filled  by 
connective  tissue. 

Necrotic  tissue  such  as  sloughing  fasciae,  necrotic  tendons  and 
particles  of  dead  bone  are  attacked  by  a  process  similar  to  that  which 
takes  place  in  the  healing  of  wounds.  The  offending  material  is  sur- 
rounded by  an  active  regenerative  inflammation  and  not  infrequently 
expulsion  of  the  undesirable  tenant  through  the  skin  is  achieved. 

A  like  process  occurs  when  foreign  material  finds  its  way  into  the 
body.  The  proliferating  granulation  tissue  is  ordinarily  not  capable 
of  sufficient  cellular  activity  to  accomplish  repair,  a  purulent  discharge 
persists  until  the  foreign  material  is  either  spontaneously  expelled  or 
removed,  when  healing  in  the  manner  described  takes  place. 

Foreign  hodies  that  cause  only  slight  irritation  and  are  accompanied 
by  few  or  no  bacteria  may  be  entirely  encapsulated  hy  connective 
tissue.  This  occurs  with  bullets  and  non-absorbable  ligature  and 
suture  material ;  the  latter  fact  taken  into  account,  together  with  the 


WOUNDS  19 

statement  made  above  regarding  catgut,  should  argue  for  the  use  of 
absorbable  ligature  and  suture  material  whenever  feasible.  The  use 
of  non-absorbable  material  should  be  restricted  to  the  class  of  cases  in 
which  it  is  especially  indicated,  such  as  replacement  of  tendons,  etc. 

Virulent  tactcria  are  at  times  encapsulated  together  with  a  foreign 
body;  years  later  trauma  at  the  site  of  the  old  injury  ma}^  result  in 
the  development  of  an  active  inflammatory  process  to  be  followed  by 
expulsion  of  the  offending  material  along  the  line  described  immedi- 
ately above.  It  is  not  improbable  that  at  the  time  of  the  original 
injury,  local  resistance  suf^ced  to  obviate  the  occurrence  of  more 
extensive  pathological  changes. 

Healing"  of  Transplanted  Tissue. —  By  transplantation  is  meant  the 
engrafting  of  tissues  that  are  entirely  separated  from  the  source  from 
which  they  were  obtained,  in  contradistinction  to  the  method  of  mak- 
ing repair  with  flaps,  a  portion  of  which  (bridges  or  pedicles)  remains 
in  continuity  with  its  source  of  nourishment  until  healing  is  accom- 
plished. 

Transplants  are  employed  for  the  purpose  of  aiding  in  the  healing 
of  large  wound  surfaces  (burns,  etc.),  with  the  view  of  obviating  inor- 
dinate cicatrical  contractures,  also  replacing  loss  of  substance  (a^oil- 
sion  of  the  scalp,  etc.). 

The  term  transplantation  is  used  when  grafts  are  applied  to  the 
surface  of  the  body.  When  transplants  are  imbedded  in  deeper 
tissues,  the  term  implantation  is  employed. 

Success  in  this  connection  is  of  course  more  readily  achieved  h\  the 
contiguous  flap  methods,  for  the  obvious  reason  that  a  source  of  nour- 
ishment to  the  transplant  is  maintained,  while  healing  takes  place  at 
the  site  of  the  area  to  be  repaired. 

The  employment  of  transplants  from  the  patient  himself  is  called 
autoplasty ;  when  taken  from  another  human  being,  homoplasfy; 
when  foreign  materials  are  used  for  the  purpose  (celluloid,  paraffin, 
gold  or  silver  wire,  etc.)  the  term  alloplasiy  (Marchand^)  is  used. 
Heteroplasty  is  a  term  employed  when  the  tissues  of  the  lower  animals 
are  used  ;  this,  however,  possesses  no  advantages  over  homoplasty. 

In  bone  implantation  the  source  of  the  graft  seems  to  make  no  great 
difference,  although  when  the  use  of  a  heterogeneous  graft  becomes 
necessary,  transplants  from  the  ape  would  seem  to  offer  the  conditions 
most  favorable  to  success. 

The  survival  of  transplants  depends  upon  a  rapid  proliferation 
of  new  blood  vessels  from  the  contiguous  tissues  which  furnish  circu- 


20  WOUNDS 

lating  fluid  in  sufficient  quantity  to  maintain  nourishment  of  the  graft. 
The  development  of  these  new  avenues  is  dependent  upon  primary 
UNION,  an  end  most  likely  to  be  achieved  v^hen  the  cellular  activity 

NECESSARY  TO  HEALING  IS  NOT  INTERFERED  WITH  BY  THE  CHEMICAL 
ACTION  OP  ANTISEPTICS,  THE  PRESENCE  OF  BLOOD  CLOT  OR  OF  INFLAM- 
MATORY EXUDATES. 

The  transplant  must  possess  sufficient  vitality  to  maintain  itself 
during  the  period  when  Mood  vessel  proliferation  is  taking  place.  It 
would  also  seem  desirable  that  the  transplant  possess  a  certain  tissue 
accord  with  the  body  receiving  the  graft ;  that  is  to  sa}',  biochemical 
changes  in  certain  individuals  probably  possess  certain  qualities  pecu- 
liar to  that  individual,  which  argues  for  the  employment  of  auto- 
genous grafts  whenever  feasible ;  also  it  would  seem  to  render  desirable 
the  emplo^-ment  of  transplants  and  implants  from  persons  who  are 
blood  relations  of  the  recipient.  It  is  conceivable  that  differences  of 
the  biochemistry  of  cells  and  sera  are  least  marked  in  blood  relations 
and  greatest  where  racial  differences  are  widest  (Lexer^). 

Experimental  observation,  supported  by  what  would  seem  to  be  fair 
inferences  based  upon  clinical  observation,  would  indicate  that  there  is 
such  a  thing  as  regional  tissue  accord.  Transplants  destined  to  pro- 
mote healing  of  wounds  of  a  given  area  when  taken  from  a  correspond- 
ing portion  on  the  opposite  side  of  the  body,  seem  to  be  more 
frequently  attended  with  successful  outcome  than  when  the  grafts  are 
obtained  from  an  arbitrarily  selected  surface. 

When  transplantation  is  unsuccessful  the  graft  is  absorbed  and 
replaced  w^ith  scar  tissue.  In  some  instances,  the  graft  undergoes 
necrosis  and  is  expelled  in  the  manner  described  above. 

Transplantation  of  skin,  mucous  membrane,  cartilage  and  bone  is 
attended  with  a  not  inconsiderable  measure  of  success.  Complete 
hemostasis  is  essential  in  all  instances. 

Skin  grafts  applied  to  fresh  or  granulating  wounds  that  have  been 
denuded  may  be  employed  by  the  method  of  either  Keverdin  or 
Thiersch  when  only  the  epidermis  and  papillary  laj'ers  are  used,  or 
they  may  consist  of  the  entire  thickness  of  the  skin  with  or  without 
subcutaneous  fat.  Skin  grafts  become  cemented  into  place  by  a  thin 
layer  of  leukocytes  and  fibrin  which  is  soon  replaced  by  fibroblasts 
and  proliferating  blood  vessels  in  exactly  the  same  manner  as  occurs 
in  primary  wound  healing  (p.  000).  The  new  Hood  vessels  project 
into  the  grafts  as  far  as  the  papillary  la^'crs  of  the  skin. 

When  Reverdin  or  Thiersch  grafts  (epidermal)  are  employed,  the 


WOUNDS  21 

superficial  epithelial  layer  exfoliates,  to  be  replaced  by  a  rapid  pro- 
liferation ;  when,  however,  the  entire  thickness  of  the  skin  is  used  its 
epidermal  layer  is  completel}^  lost,  but  is  soon  dermatized  by  prolifera- 
tion of  epithelial  cells  springing  from  remnants  of  sweat  glands  from 
which  insular  areas  are  formed  that  ultimately  coalesce  with  the 
edges  of  the  wound.  It  will  be  seen  that  here  occurs  a  process  similar 
to  the  one  described  in  connection  with  healing  under  a  scab  (p.  13). 
Healing  under  epidermal  grafts  takes  place  in  from  one  to  two  weeks ; 
when  the  entire  thickness  of  the  skin  (cuticular  strips)  is  used,  repair 
requires  from  three  to  five  weeks. 

The  graft  area  is  endowed  with  sensation  in  about  six  weeks,  as 
the  outcome  of  nerve  proliferation  from  the  surrounding  tissue. 

"When  epidermal  strips  are  used  the  area  of  transplant  is  at  first 
bluish  in  color  and  somewhat  depressed ;  gradually  the  color  fades  to 
pure  white  and  the  depression  is  obliterated.  At  times  keloids  develop 
in  this  situation. 

The  site  from  which  the  grafts  are  removed  heals  as  described 
under  the  head  of  ''healing  under  a  scab"  (p.  13).  Epidermal  grafts 
may  be  taken  from  the  same  place  the  second  time. 

Contracture  and  depression  do  not  follow  the  use  of  cuticular  trans- 
plants when  a  layer  of  fat  is  left  attached  to  the  under  surface  of  the 
graft.  At  the  end  of  five  weeks  the  graft  area  is  level  with  the  sur- 
rounding skin  and  is  movable  over  the  underlying  tissues.  Neither 
the  epidermal  nor  the  cuticular  strips  are  of  service  in  homoplasty, 
being  either  exfoliated  or  forming  a  dry  scab;  they  are  at  best 
replaced  hy  scar  tissue  (Lexer^). 

Cutaneous  and  suhcutaneous  tissue  cut  into  strips  or  flaps  and 
denuded  of  epidermis  is  ver}'^  useful  when  emploj^ed  as  pads  under 
the  skin,  or  for  the  purpose  of  replacing  tendons  and  ligaments 
(Eehn*). 

Mucous  memhrane  is  particularly  well  adapted  to  transplantation, 
large  portions  being  readih^  removed  and  aifixed  in  distal  environment. 
Transplants  taken  from  the  buccal  'cavity  may  be  grafted  into  the 
under  surface  of  eyelids ;  they  are  also  employed  in  the  formation  of 
new  mucocutaneous  surfaces  of  the  lips,  with  a  large  percentage  of 
success.  Exfoliation  of  epithelium  is  promptly  followed  by  prolifera- 
tion. Implantation  of  a  portion  of  ileum  to  replace  the  vagina,  and 
replacement  of  the  male  urethra  with  an  ablated  appendix  vermi- 
formis,  have  both  been  successfully  executed  (Lexer^). 

Cartilaginous  grafts,  when  invested  with  perichondrium,  may  be 


22  WOUNDS 

successfully  implanted.  A  small  portion  of  the  cartilaginous  concha 
has  been  used  to  replace  a  lost  ala  of  the  nose,  by  implanting  it 
between  the  layers  of  the  skin  in  this  situation;  v.  Mangoldt*'  used 
a  portion  of  costal  cartilage  to  elevate  a  sunken  nasal  bridge ;  Lexer^ 
emphasizes  the  usefulness  of  the  measures  just  related  from  the  stand- 
point of  his  own  experience.  Marchand^  insists  that  portions  of  graft 
transplanted,  without  perichondrium,  slough.  Lexer^  has  successfully 
transplanted  from  an  amputated  limb  the  entire  articular  cartilage 
together  with  a  thin  layer  of  adjacent  bone  tissue. 

Bone  transplantation  is  so  uniformly  successful,  and  so  frequently 
followed  by  such  startling  resumption  of  function,  that  a  careful  study 
of,  and  a  thorough  acquaintance  with,  the  subject  is  enjoined  upon 
the  student. 

"When  bone  transplants  are  used  for  the  purpose  of  repairing  bone 
defects,  the  process  of  healing  constitutes  one  of  the  exceptions  noted 
above  in  connection  with  the  healing  of  wounds  (p.  17).  The  results 
of  prolonged  experimental  study  and  much  carefully  conducted  clin- 
ical observation  would  seem  to  summarize  the  process  of  bone  repair 
by  bone  transplanting  as  follows : 

Transplanted  bone  tissue  dies  irrespective  of  whether  it  has  periosteum 
and  bone  marrow  attached  to  it;  whether  it  is  autoplastic,  homoplastic  or 
heteroplastic  in  origin;  whether  it  is  dead  (sterilized  by  boiling)  or  whether 
it  is  freshly  alive  at  the  time  used.  The  tissues  capable  of  ossification  spring 
from  the  edges  of  the  defect,  from  its  periosteum  and  bone  marrow,  gradually 
causing  absorption  of  the  grafted  bone  tissue  and  replacing  it  with  new  bone. 

Repair  is  accomplished  by  a  process  of  absorption  and  substitution ; 
however,  the  inorganic  constituents  of  the  bone  graft  are  concerned  in 
reparative  growth,  constituting  a  stimulus  to  bone  cell  proliferation 
(Barth«). 

Healing  is  ushered  in  by  the  formation  of  a  fibrinous  exudate  which 
soon  becomes  infiltrated  with  connective  tissue.  The  nuclei  of  the 
bone  and  marrow  cells  largely  undergo  degeneration  in  a  few  days. 
The  connective  tissue  proliferating  from  the  neighboring  tissues  soon 
penetrates  the  bone  marrow  and  haversian  canals,  carrying  with  it 
the  new  blood  vessels,  and  at  the  end  of  a  week  the  entire  bone  trans- 
plant is  surrounded  and  infiltrated  with  newly  formed  connective 
tissue ;  the  replacement  of  degenerated  marrow  cells  requires  a  some- 
what longer  period  of  time. 

The  growth  of  new  bone  begins  with  the  appearance  of  osteoblasts 
that  attach  themselves  (about  the  fifth  da.y)  to  the  degenerating  bone 
transplant,  and  form  new  bone  lamellae  (Fig.  6). 


WOUNDS 


23 


nk 

Fig.  6. —  Bone  Formation  at  the  Margin  of  a  Medullary  Cavity  and  About 
THE  Haversian  Canals. 

(Freshly  transplanted  bone  as  it  appears  miscroscopically  after  forty-nine  days.) 
(After  Marchand.) 

o,  osteoblasts;  Ic,  newly  formed  bone;  iiTc,  bone  which  has  become  necrotic;  g,  an 
injected  blood  vessel. 


Osteoclasts  are  also  concerned  in  causing  absorption  of  the  graft 
by  the  formation  of  giant  cells.  The  more  rapidly  new  layers  of 
cellular  elements  are  formed,  the  sooner  does  the  bone  graft  disappear. 
The  same  character  of  process  occurs  when  ivory  pegs  are  used  for 
purposes  of  repair,  newly  formed  bone  invading,  and  ultimately 
replacing  them. 

When  fresh  autogenous  bone  tissue,  together  with  its  periosteum,  is 
implanted  into  the  soft  parts  not  m  contact  with  bone,  the  periosteum 
not  alone  lives,  but  also  develops  a  growth  of  new  bone.     The  same 


24  WOUNDS 

may  be  said  with  regard  to  the  bone  marrow  attached  to  a  similar 
graft.  The  bone  tissue  itself,  however,  dies  and  is  replaced  by  new 
osseous  tissue  (Sultan"). 

It  is  not  reasonable  to  assume  that  periosteum  should  possess  the 
quality  of  bone  growth  when  it  is  implanted  into  soft  parts,  and  not 
possess  this  same  quality  when  used  for  the  purpose  of  repairing  bone. 

As  a  matter  of  fact  all  fresh  bone  transplants,  with  periosteum 
attached,  do  develop  new  bone  cells  in  which  process  the  periosteum 
plays  the  all-important  part  (Axheusen^").  The  presence  of  bone 
marrow  cells  contributes  somewhat  to  this  process,  but  need  not  be 
regarded  as  essential. 

In  the  repair  of  bone  defects  living  bone  grafts  with  the  periosteum 
attached  possess  the  advantage  of  contributing  a  not  inconsiderable 
portion  of  new  elements  to  the  general  callus,  though  this  is  mostly 
donated  by  the  contiguous  bone  itself.  When  large  bone  defects  are 
subjected  to  osteoplasts^  the  fact  just  stated  is  important,  as  it  is  fair 
to  assume  that  the  affliction,  for  the  relief  of  which  the  graft  is 
inserted,  has  already  to  a  not  inconsiderable  extent  impaired  the  bone 
producing  ability  of  the  area  involved. 

It  is  therefore  good  practice  to  employ  dead  bone  (from  the  cadaver) 
as  grafts,  when  it  is  possible  to  implant  under  periosteum  or  for  the 
purpose  of  a  medullary  graft,  which  may  be  introduced  into  the 
spongiosa  or  medullary  cavity  of  long  bones.  If  the  defect  is  denuded 
of  periosteum,  it  is  best  to  use  autogenous  fresh  material  with  its 
periosteal  covering  and  some  marrow  attached  to  its  under  surface 
(crest  of  the  tibia,  portion  of  rib,  etc.). 

Lexer^^  has  successfully  employed  an  entire  bone  shaft  together 
with  its  epiphysis  and  articular  cartilage  in  the  repair  of  a  knee  joint. 

Muscles  and  nerves  when  transplanted  in  toto  undergo  degeneration, 
and  therefore  are  of  no  service  as  far  as  restoration  of  function  is 
concerned.  Free  tendon  transplants,  taken  either  from  the  patient 
himself  or  from  amputated  limbs,  unite  readily  in  new  environment 
and  are  later  capable  of  functioning  (Rehn*). 

Fatty  tissue  transplantation  seems  to  possess  marked  value,  espe- 
cially when  the  autoplastic  method  is  employed.  Fat  transplants  are 
used  to  fill  cavities  in  the  face  for  cosmetic  effect.  Czemey  success- 
fully implanted  a  lipoma  following  excision  of  the  breast  for  adeno- 
fibroma. 

Suhcutaneous  fat  transplants  taken  from  the  outer  aspect  of  the 
thigh  and  the  abdominal  wall  are  introduced  between  the  surfaces  of 


WOUNDS  25 

ankylosed  joints.  Similar  grafts  are  used  to  imbed  tendons  and 
nerves  involved  in  sear  tissue,  and  are  placed  in  defects  remaining 
after  excision  of  portions  of  dura  and  brain.  KanaveP"  has  had 
striking  results  in  this  connection,  especially  in  cases  of  contractural 
deformity  and  loss  of  function  following  infection  of  the  hand.  In 
instances  where  progressive  contracture  of  scar  tissue  has  interfered 
with  circulation,  KanaveP-  has  embedded  in  fat  transplants  the 
affected  blood  vessels  together  with  tendons  and  nerves,  with  remark- 
able resumption  of  function. 

Transplaniation  for  suhstitidion  of  lost  seclions  of  hlood  vessels  is 
now  an  established  method  of  procedure.  For  this  purpose  a  con- 
tiguous vein  is  best  employed,  the  new  vessel  being  placed  in  situ  by 
circular  end  to  end  suturing.  One  would  expect  the  thin  wall  of  the 
vein  to  dilate  under  the  arterial  pressure ;  this  is,  however,  not  the 
case,  as  the  walls  of  the  implanted  vein  undergo  spontaneous  h^-per- 
trophy.  Patency  of  the  implant  is  clinically  proved  by  the  fact  that 
when  pressure  is  made  upon  it,  the  pulsation  in  peripheral  arteries 
may  be  abolished  (Lexer^^).  Vessel  implants  of  homo-  and  hetero- 
plastic origin  undergo  gradual  degeneration,  but  are  replaced  by 
endothelium  proliferating  from  the  contiguous  tissues.  It  is  best  to 
use  transplants  of  autogenous  origin,  as  they  are  less  liable  to  be 
attended  with  the  formation  of  thrombi. 

Implantation  of  portimis  of  organs  is  of  doubtful  practical  value. 
In  cases  of  m^-xedema,  following  th^Toidectomy,  homoplastic  implan- 
tation of  hyperthyroid  tissue  has  been  done;  although  regeneration 
after  healing  has  been  observed  and  temporary  improvement  takes 
place,  the  procedure  has  not  been  followed  by  ultimately  satisfactory 
results.  Payr^*  reports  marked  temporary  improvement  in  infantile 
mj-xedema.  Kocher^'^  claims  good  results  following  homoplastic 
implantation  of  hyperthroid  tissue  into  the  upper  segment  of  the  tibia. 
Immediate  homoplastic  transplantation  of  parathyroid  tissue,  in  cases 
of  thyroid  tetany  following  complete  thyroidectomy,  has  obviated  a 
fatal  result ;  however,  the  implants  gradually  undergo  degeneration, 
and  a  fatal  ultimate  outcome  is  to  be  expected  unless  the  lost  internal 
secretion  is,  in  the  meantime,  supplied  by  phj'siological  substitution 
on  the  part  of  some  other  organ  or  organs. 

The  transplantation  of  entire  organs,  such  as  the  kidney,  by  means 
of  blood  vessels  anastomosis  (Carrel,  Guthrie,  etc.^^)  has  been  success- 
fully executed.  Organs  transplanted  in  this  manner  do  not  live 
(Borst  and  Enderlen^')  ;  even  temporary  success  is  attained  only  by 


26  WOUNDS 

a  so-called  reimplantation  autoplast}^;  that  is,  the  organ  is  removed 
and  immediately  reimplanted  into  the  same  animal.  This  procedure 
may  be  regarded  as  instructive  in  its  bearing  on  the  general  subject 
of  implantation,  but  at  this  writing  it  need  not  be  given  other 
significance. 

Alloplasty  (the  introduction  of  foreign  material)  is  used  for  certain 
purposes,  such  as  closure  of  defects  in  the  skull,  elevation  of  a  saddle 
nose  or  obliteration  of  hernial  ports,  but  is  not  as  useful  in  this  con- 
nection as  are  the  various  tissues  described  above.  The  substances 
commonly  used  are  plates  of  platinum,  celluloid,  silver  wire  gauze, 
ivory  pegs,  etc.  If  aseptically  introduced,  these  substances  are  usually 
well  tolerated,  although  in  a  not  inconsiderable  number  of  cases, 
fistulae  develop  at  the  site  of  the  implantation,  and  the  foreign  sub- 
stance is  expelled.  Injection  of  liquid  paraffin  is  used  for  the  purpose 
of  elevating  the  skin  (saddle  nose,  etc.).  This  substance  has  also  been 
injected  into  the  scrotum  after  orchidectomy,  the  injected  fluid  solid- 
ifying in  a  form  simulatmg  the  testicle.  The  use  of  paraffin  in  the 
latter  instance  of  course  conserves  cosmetic  effect  rather  than  restora- 
tion of  function.  However,  the  moral  effect  upon  the  patient  probably 
needs  to  be  shared  in  order  to  obtain  the  best  result,  though  this  is 
only  transitory,  as  absorption  of  the  injected  material  ultimately  takes 
place. 

BIBLIOGRAPHY 

1.  Marchand.     Deutsch.  Chir.  1901,  with  lit. 

2.  Reinbach.     Beitr.  z.  path.  Anat.  Bd.  30,  1901. 

3.  Lexer.     Chir.  tons:.  Vehr.  1908,  Bd.  ii. 

4.  Rehn.     Beitr.  z.  kUn.  Chir.  Bd.  68,  1910. 

5.  Lexer.     Med.  Clinic.  1911. 

6.  v.  Mangoldt.     Zentrbl.  f.  Chir.  1907. 

7.  Lexer.     Chir.  kong.  Vehr.  1904,  Bd.  ii. 

8.  Barth.     See  Marchand  No.  1. 

9.  Sultan.     Chir.  koni?.  Vehr.  1902,  Bd.  i. 

10.  Axheusen.     Arch,  f .  klin.  Chir.  Bd.  88,  1905. 

11.  Lexer.    All^.  Chir,  (7th  ed.)  Bd.  i,  Stuttsart,  1914. 

12.  Kanavel.     infections  of  the  Hand,  N.  Y.,  1916. 

13.  Lexer.     Chir.  kong.  Vehr.  1913,  i. 

14.  Patr.     Chir.  kong.  Vehr.  1906,  ii. 

15.  Kocher.     Chir.  kong.  Vehr.  1908,  ii. 

16.  Carrel  and  Guthrie.     Brit.  Med.  Jr.,  1906,  Dec.  22d. 

17.  BORST  and  Enderlen.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  99,  1909. 


CHAPTER  II 

CLASSIFICATION    OF    WOUNDS 

A  wound  is  generally  defined  as  a  sudden  solution  of  continuity  of 
soft  parts,  a  terminology  perhaps  as  definite  as  the  effort  to  reduce  the 
question  to  a  concrete  statement  will  allow.  An  incised  wound  of  a 
limb,  involving  the  underlying  bone,  is  certainly  not  alone  a  solution 
of  continuity  of  soft  parts.  Trauma  to  bone  is  taken  up  under  the 
head  of  fractures,  yet  the  latter  term  would  surely  not  describe  the 
condition. 

Womids  have  heen  defined  as  a  more  or  less  gaping  separation  of 
the  coverings  of  the  body,  its  mucous  membranes,  and  the  surfaces  of 
organs ;  with  a  further  qualification  of  a  division  into  simple  wounds, 
i.  e.,  those  involving  skin  and  mucous  membrane;  and  complicated 
wounds,  i.  e.,  those  which  also  involve  muscles,  nerves,  bones,  joints, 
large  blood  vessels  and  the  great  cavities.  The  latter  terminology 
conveys  a  more  accurate  notion  than  is  offered  by  the  more  concise 
definition  generally  used,  and  therefore  is  recommended  for  acceptance 
on  the  plea  that  brevity  is  not  desirable  when  achieved  at  the  expense 
of  accuracy. 

Wounds  are  classified  in  accord  with  the  form  they  take,  as  the 
outcome  of  the  character  of  the  force  producing  them.  Incised,  con- 
tused, and  lacerated  wounds  comprise  the  three  principal  divisions 
under  this  head. 

Incised  wounds  arc,  as  the  term  implies,  produced  by  a  cutting 
force,  such  as  a  knife  or  glass  splinters,  and  are  characterized  by 
smooth  edges  and  surfaces.  The  agent  producing  an  incised  wound 
must  be  sharp  and  applied  to  the  body  with  gentle  sweeping  pressure. 
A  wound  produced  by  a  saber,  a  butcher's  cleaver,  or  a  dull  knife  is 
the  result  of  a  cutting  force,  yet,  when  these  instruments  are  applied 
with  sufficient  force  to  cause  ecchjTnosis  and  swelling,  it  makes  a 
definite  characterization  of  the  condition  difficult,  unless,  perhaps,  the 
term  contused-incised  M^ound  is  used  in  this  connection. 

A  more  comprehensive  conception  of  the  subject  matter  under  dis- 

27 


28  WOUNDS 

cussion  is  conserved  when  no  attempt  is  made  at  categorical  classifica- 
tion, as  effort  at  distinctive  terminology  is  at  times  only  confusing. 

The  extent  to  which  incised  wounds  of  the  skin  gape  depends  upon 
their  direction  as  related  to  the  lines  of  tension  of  the  skin.  If  the 
direction  of  the  wound  is  at  right  angles  to  the  normal  lines  followed 
by  the  skin  in  its  embryological  development,  the  wounds  gape  widely ; 
if,  however,  the  direction  of  the  wound  is  parallel  to  the  lines  of 
tension,  even  very  extensive  ones  will  lie  with  their  edges  apposed ; 
this  should  be  borne  in  mind  by  the  surgeon.  In  this  connection 
Kocher^  states,  that,  when  making  skin  incisions,  he  invariably  follows 
"Langer's  lines  of  cleavage,"  especially  when  operating  upon  the  face 
and  neck,  in  which  situation  he  has  been  able  to  remove  large  tumors 
with  barely  perceptible  scarring  as  a  sequel. 

When  a  cutting  force  is  applied  in  an  oblique  direction,  the  skin 
may  be  loosened  from  the  body  in  the  form  of  a  flap,  remaining 
attached  by  a  pedicle;  if,  however,  an  area  is  entirely  denuded  of 
skin  in  this  manner,  the  term  loss  of  sultsiance,  or  defect  is  used. 

A  punctured  wound  is  a  modified  incised  wound.  If  the  causative 
factor  is  a  sharp-pointed  instrument  (needle,  dagger,  trocar,  etc.),  the 
edges  of  the  wound  will  be  smooth,  and  the  lesion  differs  from  an 
incised  wound  only  in  its  extent.  If  the  puncturing  instrument  is 
dull  (nail,  lance,  arrow,  stick,  umbrella,  etc.),  the  edges  of  the  punc- 
ture will  be  contused  and  here,  to  be  exact,  we  would  have  to  use  the 
term,  contused-punctured  wound. 

Punctured  wounds  do  not  gape,  and,  when  not  -infected,  heal  rap- 
idly. They  are,  however,  very  likely  to  be  the  seat  of  foreign  bodies 
that  escape  detection. 

Contused  wounds  are  the  result  of  blunt  force  (blows  from  a  club, 
stone,  hoof,  etc.),  and  are  characterized  hy  more  or  less  extensive 
subcutaneous  hemorrhage  that  distends  the  edges  of  the  wound  and 
contiguous  tissues  to  a  degree  varying  with  the  severity  of  the  causa- 
tive force.  If  the  subcutaneous  tissue  is  crushed  and  the  skin  is 
forcibly  torn  from  its  subjacent  attachment,  as  the  result  of  obliquely 
applied  force ;  large  hematomata  form  and  the  skin  is  likely  to  hang 
down  from  the  injured  area  in  the  form  of  irregular  flaps.  A  con- 
tusion may  be  attended  with  extensive  subcutaneous  solution  of  con- 
tinuity, and  the  skin  present  only  a  moderate  degree  of  abrasion. 
When  the  surface  of  the  skin  is  separated  in  this  class  of  injury  one 
would,  in  order  to  be  accurate,  have  to  call  the  injury  a  lacerated- 
contused  wound. 


CLASSIFICATION  OF  WOUNDS  29 

Contused  wounds  are  more  likely  to  occur  in  situations  in  which 
soft  parts  are  closely  apposed  to  hone.  Contused  wounds  gape  in 
accord  with  their  direction  and  the  ami3unt  of  subcutaneous  bleeding ; 
extensive  contusion  of  the  stomach  ajid  intestines  occurs  when  these 
parts  are  crushed  against  the  spinal  column. 

At  times,  contusion  of  deeply  located  parts,  organs,  and  tissues 
occurs,  when  the  external  evidence  of  injury  is  very  slight;  such  as 
the  occurrence  of  minute  hemorrhagic  spots  in  the  cerebro-spinal 
centers,  which  ultimately  may  lead  to  considerable  interference  with 
function ;  this  class  of  cases  is,  however,  more  especially  taken  up  in 
comiection  with  injuries  to  organs. 

Lacerated  wounds  are  caused  by  tearing  and  stretching  forces  which 
are  directed  against  the  body  in  an  oblique  direction.  The  edges  of 
lacerated  wounds  are  irregular  and  ragged,  and  are  attended  with 
less  bloody  infiltration  of  the  contiguous  tissues  than  are  contused 
wounds. 

Ruptured  or  bursting  wounds,  the  result  of  explosions  that  injure 
the  skin,  or  that  are  the  outcome  of  crushing  force  applied  to  the  liver, 
spleen,  kidneys,  etc.,  take  on  the  characteristics  of  lacerated  wounds 
and  are  classified  as  such. 

As  already  stated,  contusion  and  laceration  of  the  tissues  frequently 
coexist.  This  obtains  most  frequently  when  injuries  are  the  result  of 
biting,  scratching,  the  impact  of  projectiles,  or  tearing  with  machine 
gears,  etc. 

"When  a  projectile  furrows  or  strikes  sidewise  the  resultant  wound 
may  be  properly  classified  as  lacerated  or  contused,  or  both,  in  contra- 
distinction to  those  gunshot  wounds  that  have  ports  of  entrance  or 
exit,  or  both.  Grenade  splinters  and  shrapnel  most  frequently  produce 
lacerated  wounds. 

Symptoms  of  Wounds. —  Pain,  hemorrhage  and  gaping  are  the 
cardinal  symptoms  of  all  wounds,  although  any  one  or  two  of  these 
may  predominate  in  various  kinds  of  wounds,  in  accord  with  their 
causation  as  expressed  in  the  classification  given  above. 

The  constitutional  symptoms  of  wounds  are  those  of  shock  and  acute 
anemia  (p.  46),  and  are  most  frequently  manifested  in  complicated 
wounds. 

Pain  is  at  its  maximum  during  the  production  of  a  Avound,  and 
varies  greatly  in  degree,  depending  upon  the  character  of  wound,  the 
producing  force,  the  location  traumatized,  and,  to  some  extent,  upon 
the  relative  sensibility  of  the  injured  person.     The  more  rapidly  the 


30  WOUNDS 

tissues  are  divided  and  the  sharper  the  instrument  producing  the 
wound,  the  less  severe  the  pain.  Wounds  involving  the  cornea, 
tongue,  lips,  finger  tips,  the  external  genitals  and  the  anal  regions,  are 
particularly  painful.  Wound  pain  is  described  as  burning  in  character 
and  fluctuates  with  pulsation. 

Pain  is  due  to  the  involvement  of  sensory  nerve  fibers  and  disappears 
soon  after  immobilization  of  the  injured  part,  and  application  of  the 
protective  dressing.  Pain  disappears  most  rapidly  in  clean,  incised 
wounds,  the  edges  of  which  lie  in  apposition,  or  are  closed  by  sutures. 

Gunshot  wounds  produced  by  projectiles  of  high  velocity,  and 
severe  contused  wounds,  together  with  their  surrounding  tissues,  may 
be  numb  or  totally  insensible  for  many  hours  or  several  days,  as  the 
result  of  concussion  of  peripheral  nerves ;  this  condition  is  called 
tissue  shock,  and  usually  is  accompanied  by  a  slight  constitutional 
shock. 

Ilemorrhage  is  most  copious  from  simple  wounds,  when  they  are 
produced  by  a  sharp  cutting  force.  The  more  contusion  and  lacera- 
tion, the  less  bleeding.  Crushed  and  torn  blood  vessels  do  not  remain 
open,  their  lumen  being  closed  by  the  crushing  together  of  their  inner 
surfaces,  the  curling  inward  of  the  torn  ends  by  contracture  of  the 
muscular  fibers,  and  b}''  the  formation  of  blood  clot,  a  condition  that 
obtains  even  though  large  arterial  trunks  are  divided. 

Bleeding  is  described  as  capillary  (from  organs,  parenchymatous), 
arterial  and  venous. 

Capillary  hleeding  is  characterized  by  a  slow,  constant  trickling  of 
blood  from  the  wound  surface. 

Arterial  hleccling  is  characterized  by  its  propulsive,  remittent  pro- 
jection, the  flow  being  at  its  maximum  during  ventricular  systole. 
Arterial  blood  is  bright  red,  except  in  cases  of  dyspnea,  when  it 
becomes  dark  red  in  color. 

Venous  bleeding  flows  in  a  slow  steady  stream  and  is  dark  red  in 
color.  A  large  quantity  of  blood  emanates  from  veins  when  the  return 
circulation  is  interfered  with,  and  venous  hemorrhage  is  most  profuse 
when  the  great  plexuses,  such  as  the  pampiniform  and  pterygoid,  are 
injured. 

Primary  hemorrhage  occurs  at  the  time  the  injury  is  inflicted ;  sec- 
ondary hemorrhage  occurs  when  the  hemostatic  coagula  disappear 
from  the  ends  of  the  blood  vessels  as  the  result  of  mechanical  force 
(increased  blood  pressure)  or  by  pyogenic  or  putrefactive  disintegra- 
tion. 


CLASSIFICATION  OF  WOUNDS  31 

Incised  wounds  present  conditions  most  favorable  for  repair;  the 
absence  of  dead  spaces  and  of  irregular  edges  which  might  harbor 
infectious  bacteria,  and  of  torn  fragments  that  might  undergo  necrosis, 
makes  the  achievement  of  primary  union  a  comparatively  simple 
problem.  Per  contra:  Wounds  wath  torn  irregular  surfaces  are  very 
liable  to  infection  and  therefore  are  more  likely  to  heal  by  granulation. 


BIBLIOGRAPHY 

KocHER.     Operative  Surgery,  Berlin  and  Leii^zig,  1895. 


CHAPTER  III 

THE    TEEATMENT    OF    WOUNDS 

The  first  step  in  the  treatment  of  wounds  is  arrest  of  hemorrhage; 
this  may  be  divided  into  temporary  and  permanent  hemostasis. 

The  temporary  arrest  of  hemorrhage  is  indicated  as  an  immediate 
measure  of  relief  in  accidentally  inflicted  wounds.  The  ph3'sician  or 
la^'man  who  undertakes  to  employ  efforts  directed  toward  the  arrest  of 
hemorrhage  must,  above  all,  guard  against  doing  more  harm  than  good 


'^  1 


Fig.  7. —  Digital  Pressure  on  Femoral  Artery. 

Measures  of  relief  that  disregard  the  danger  of  infection  are 
justifiable  only  mrhen  large  blood  vessels  are  the  source  of 
bleeding,  the  immediate  arrest  of  v^hich  is  necessary  to  save  life. 
Pressure  applied  to  the  wound  with  the  bare  hand,  handkerchief, 
sponges,  etc.,  increase  the  danger  of  infection,  as  does  the  use  of 
chemical  hemostatics,  such  as  cold  tap  or  spring  water,  alum,  vinegar, 
albumin  water,  salt  solution,  zinc  chloride,  etc.,  all  of  which  liberate 

32 


THE  TREATMENT  OF  WOUNDS 


33 


infectioas  organisms  from  the  contiguous  tissues  and  spread  1hem  into 
the  vound  area. 


Fig.  8. —  Improvised  Tourniquet. 

Caustic  agents  damage  the  wound  surfaces  and  thus  create  local 
conditions  favorahle  to  the  development  of  inflammatory  processes. 

For  these  reasons  lavage  or 
sponging  of  the  wound  and  the 
application  of  direct  pressure  are 
to  be  deprecated  unless  sterile 
material  is  used  for  the  purpose. 
The  wound  should  not  be  cleansed 
of  foreign  substances  or  clots,  but 
for  immediate  relief,  sterile 
gauze  should  be  firmly  pressed 
upon  the  site  of  the  injur}'  and 
held  in  place  by  bandages ;  in 
this  way  even  sharp  arterial 
hemorrhage  may  be  controlled. 
In  an  emergency,  freshly 
laundered  towels  may  be  used 
in  place   of  sterile   gauze;   if 

^       ,     •  ,  neither  of  these  is  available, 

Petit  's  Tourniquet  Applied 

TO  Brachial   Artery.  it  is  BETTER  TO  LEAVE  THE  WOUND 


Fig.  9.- 


34  WOUNDS 

UNTOUCHED   THAN   TO    USE   SOILED    MATERIAL.       Even   the    USe    of    moist 

antiseptic  gauze  is  objectionable,  on  the  ground  that  moisture  favors 
the  spread  of  bacteria. 

Violent,  menacing  arterial  bleeding  is  best  met  by  central  pressure 
on  the  main  artery  leading  to  the  site  of  hemorrhage,  together  with 
vertical  elevation  of  the  limb.  In  the  absence  of  other  agents,  digital 
pressure  (Fig.  7)  or  an  improvised  tourniquet  (Fig.  8)  may  be 
employed. 

For  the  use  of  the  surgeon  many  kinds  of  tourniquets  have  been 
devised,  although  none  would  seem  to  possess  any  great  advantages 
over  the  one  devised  by  Petit  many  years  ago  and  which  is  ap- 
plied in  the  manner  shown  (Fig.  9).  The  United  States  Army 
Tourniquet  shown  in  Fig.  10  is  extremely  useful  in  this  connection. 
As  a  matter  of  fact,  the  arrest  of 

a  hemorrhage  by  means  of  a  ^^ffff^^^lj-^^;^::;;;^;?^^^^^^ 
tourniquet  is  to  be  avoided  if  pos- 
sible. As  a  tourniquet,  the  rubber 
elastic  bandage  of  v.  Esmarch,'- 
held  in  place  by  Langenbeck's 
clamp  (Fig.  11),  while  extremely 
useful  in  the  hands  of  the  surgeon, 
should  not  be  used  unless  perma- 
nent   control     of    hemorrhage    is    .^      ^^      tt  r,    .         r^ 

^^  Fig.  10. —  U.  S.  Army  Tourniquet. 

imminent,     on     the    ground    that 

strangulation  of  the  tissues  may  do  serious  damage ;  an  objection  that 
is  more  or  less  applicable  to  all  forms  of  tourniquets. 

For  the  temporary  arrest  of  bleeding  from  the  popliteal  space,  the 
leg  may  be  forcibly  flexed  upon  the  thigh  and  fixed  in  this  position. 
This  condition  of  aifairs  should  be  maintained  only  for  a  brief  period 
of  time,  for  the  reason  stated  above,  i.  e.,  fear  of  strangulation  of  the 
tissues. 

Severe  hemorrhage  from  mucous  membranes,  when  accessible,  such 
as  the  nose,  mouth,  uterus,  vagina,  and  rectum,  is  best  arrested  by 
packing  with  dry  sterile  or  dry  antiseptic  gauze.  As  mucous  mem- 
branes are  secreting  surfaces,  frequent  changing  of  the  compressing 
agent  together  with  lavage  with  mildly  styptic  antiseptics,  such  as 
hydrogen  peroxid,  adrenalin  solution,  etc.,  is  indicated. 

To  obtain  temporary  exsanguination  of  limbs,  during  operations, 
the  employment  of  v.  Esmarch's  elastic  bandage  is  of  value.  The 
bandage  is  applied  firmly  to  the  limb  in  a  spiral  manner,  from  the 


THE  TKEATMEXT  OF  WOUNDS 


35 


distal  extremity  to  a  good  distance  above  the  site  of  tlie  pro- 
posed operation,  and  is  tlien  supplemented  b}-  a  rubber  girdle 
passed  firmly  around  the  limb;  at  this  point  held  by  forceps  or  a 
clasp  (Fig.  12),  after  which  the  elastic  bandage  is  removed  from  below 
upward. 

"Like  many  useful  things,  the  v.  Esmarch  bandage  has  objectionable 
features,  the  removal  of  the  bandage  is  often  followed  by  persistent 
oozing  of  blood;  its  application  may  force  into  the  circulation  dele- 


FiG.  11. —  Last  Tukns  of  v.  Esmaech's  Bandage  Held  in  Place  with  L.vngen- 
beck's  Clamp;  Distal  Turns  Eemoved. 


terious  agents;  its  use  may  temporarily  paralyze  the  part  to  which  it 
was  applied  and  cause  more  or  less  transient  disturbances  of  the 
general  circulation.  These  objections  are  not,  however,  sufficiently 
important  to  contra-indicate  emplo\Tnent  of  the  bandage.  The  ten- 
dency to  severe  oozing  is  an  objection  that  must  stand  against  the 
use  of  the  agent,  though  arrest  of  oozing  is  readily  accomplished  by 
the  employment  of  proper  measures. 

''  The  power  to  force  improper  products  from  diseased  or  injured 
parts  into  the  general  circulation  can  be  obviated  by  omitting  the 
application  to  these  parts  —  that  is,  by  raising  the  limb  and  holding  it 
until  it  is  well  depleted  by  force  of  gravity,  then  applying  the  bandage 
to  the  sound  parts,  central  to  the  seat  of  injury  or  disease,  passing 
very  lightly  over  or  omitting  altogether  these  parts  on  the  way  up  to 


36 


WOUNDS 


the  seat  of  operation,  and  then  using  the  rubber  band  as  before  "  (J. 
D.  Bryant^). 

When  severe  hemorrhage  occurs  from  injury  close  to  the  trunk  of 
the  body,  the  limb  may  be  exsanguinated  by  means  of  the  v,  Esmarch 
elastic  bandage ;  the  girdle  applied  close  to  the  pelvis  and  prevented 
from  slipping  downward  by  large  pins  introduced  in  the  manner 
shown  (Fig.  13).  This  measure  is  equally  applicable  in  the  region  of 
the  shoulder  joint  (Wyeth^). 

Momburg*  recommends  that,  after  the  lower  extremeties  are 
rendered  bloodless  by  means  of  posture  and  the  application  of  v.  Es- 
march's  bandage,  the  abdomen  be  firmly  encircled  at  a  point  midway 
between  the  crest  of  the  pelvis  and  the  lower  border  of  the  12th  rib, 
with  from  two  to  four  turns  of  a  heavy  (thickness  of  the  index  finger) 


Fig.  12. —  v.  Esmarcii  's  Bandage  and  Girdle  Applied. 


V.  Esmarch  girdle,  drawn  gradually  tighter,  until  pulsation  in  the 
femoral  artery  at  Poupart's  ligament  is  obliterated.  This  measure  is 
not  without  danger  and  its  use  is  justifiable  only  when  specially  indi- 
cated. 

Permanent  arrest  of  hemorrhage  is  accomplished  by  means  of  aseptic 
tamponade,  pressure  and  ligature;  the  thermocautery,  styptics  and 
so-called  angiotripsy  or  torsion  are  to  be  used  only  in  instances  where 
they  are  specially  indicated. 

The  final  arrest  of  hemorrhage  from  accidentally  inflicted  wounds 
is  undertaken  after  the  contiguous  surfaces  have  been  thoroughly 
cleansed  and  disinfected;  during  this  time  the  wound  is  kept  covered 
with  a  sterile  pad  to  prevent  the  entrance  of  infection ;  after  removal 
of  the  pad,  bleeding  points  are  ligated  as  in  operation  wounds. 
Capillary  and  venous  oozing  is  arrested  by  means  of  iodoform  gauze 


THE  TREATMENT  OF  WOUNDS 


37 


tamponade,  which  is  effectual  and  does  not  sufficiently  damage  the 
tissues  to  interfere  with  healing.  This  gauze  is  recommended  for 
packing  hollow  wounds,  iiecrotic  wound  areas,  and  bleeding  cavities, 
such  as  the  nose  and  vagina,  also  for  the  relief  of  parenchjonatous 
bleeding  consequent  to  rupture  of  the  liver,  spleen,  kidney,  etc. ;  and 
although  the  thermocauter}^  and  ligature  are  equally  effective  as 
hemostatics,  the}^  interfere  to  a  greater  extent  with  healing. 

The  thermocautery  is  used  for  the  purpose  of  arresting  hemorrhage 
in  instances  where  primary  union  is  not  the  aim,  such  as  cauterization 
of  hemorrhoidal  stumps,  in  which  cicatricial  contraction  consequent  to 


Fig  13. —  Constricttng  Girdle  Held  in  Place  by  Wyeth  Pins. 


healing  is  desirable.  The  thermocautery  is  also  used  when  an  infec- 
tious area,  such  as  the  cecal  end  of  the  appendix  vermiformis  or  the 
stumps  of  ablated  purulent  fallopian  tubes  are  exposed  during  an 
otherwise  aseptic  operation,  with  the  view  of  obviating  infection.  The 
thermocautery  is  advantageously  used,  when  excision  of  vascular  sar- 
comata, carcinomata  and  hemangiomata  is  practiced,  in  which  class 
of  cases  the  objection  to  its  use  would  seem  to  be  outweighed  for 
obvious  reasons.  For  this  purpose  heated  metal  is  employed.  The 
benzine  vapor  apparatus  of  Paquelin  (Fig.  14)  familiar  to  all,  is, 
perhaps,  more  useful  than  any  other  device,  except  the  electrocautery, 
of  which  there  are  many  kinds  on  the  market.     It  seems   hardly 


38 


WOUNDS 


necessary  to  add  that  the  source  of  heat  for  cauterization  is  immaterial, 
and  that  the  absence  of  instruments  of  refinement  need  not  act  as  a 
deterrent  in  cases  where  the  use  of  the  cautery  is  indicated. 

Hemorrhage  from  operative  wounds  is  properly  arrested  by  means 
of  the  ligature,  to  accomplish  which  the  bleeding  vessels  are  at  first 


Fig   14. —  Pacquelin  's   Tiiermo-Cautery. 

grasped  by  suitable  forceps  which  act  as  temporary  hemostats  and 
make  possible  effective  application  of  the  ligature.  For  the  purpose, 
a  sufficient  number  of  instruments,  called  artery  forceps,  have  been 
devised  to  make  it  literally  necessary  to  devote  a  whole  volume  to  the 
subject  in  order  to  include 
them  all.  Here  only  the 
principles  involved  are  pre- 
sented. 

The  three  varieties  of 
artery  forceps  shown  (Fig. 
15)  are  the  straight,  curved 
and  blunt  forceps.  The  first 
two  fill  the  same  office,  the 
blunt  and  broader  one  being  used  for  the  arrest  of  bleeding  from  wide 
surfaces. 

When  a  vessel  is  divided  it  is  immediately  grasped  between  the 
serrated  blades  of  the  instrument,  which  is  then  locked  and  left  in  situ 
for  subsequent  deligation.    When  a  number  of  f orcipressures  are  to  be 


Fig.  15. —  Forcipressure. 


THE  TREATMENT  OF  WOUNDS 


39 


left  attached  until  completion  of  the  operation,  the  curved  forceps 
(Fig.  15)  are  most  readily  kept  out  of  the  way. 

When  forcipressure  are  left  attached  to  the  ends  of  divided  small 
vessels  for  several  minutes,  deligation  is  frequently  unnecessary,  spon- 
taneous arrest  of  hemorrhage  having  been  accomplished  by  the  crush- 
ing force  of  the  instrument,  as  already  described  in  connection  with 
lacerated  wounds  (p.  30). 


Fig.  16. —  Ligature  by  Transfixion. 


Catgut  is  the  material  of  choice  in  deligation  of  blood  vessels  in 
aseptic  wounds  which  are  to  be  closed  b}'  suture.  The  use  of  silk  is 
preferable  in  septic  wounds  or  when  wounds  are  to  remain  open. 

The  clamped  vessel  is  surrounded  with  the  ligature  material  by 
simply  encircling  the  tip  of  the  forceps,  from  which  the  ligature 
readily  glides  into  place ;  care  should  be  taken  to  employ  a  sugeon  's 


40 


WOUNDS 


knot,  or  a  square  knot,  to  avoid  slipping,  wliich  is  liable  to  happen 
when  the  granny  knot  is  used  (p.  63). 

When  deligating  blood  vessels  of  considerable  size  security  is 
obtained  with  greater  certainty  by  delivering  from  the  surrounding 
tissues  a  potion  of  the  blood 
vessel  by  means  of  the  forceps 
and  passing  horizontally  a  sec- 
ond forceps  beneath  the  first; 
the  ligature  is  tied  central  to  the 
second  forceps. 

When  it  is  necessary  to  in- 
clude in  the  grasp  of  the  forceps 
tissue  contiguous  to  a  divided 
blood  vessel,  and  the  ligature  is 
liable  to  slip,  transfixion  ligature 
is  employed.  The  catgut  liga- 
ture is  introduced  close  to  the 
point  of  the  forceps  by  means  of 
a  curved  needle  (Fig.  16),  and  a 
single  knot  is  tied,  then  the  liga- 
ture is  carried  to  the  opposite 
side  of  the  forceps  and  tied  wuth  a  square  knot  (Fig.  17). 

Blood  vessels  that  are  exposed  in  their  continuity  during  the  opera- 
tion are  clamped  between  two  forceps,  and  divided  by  the  knife  and 


Fig. 


17. —  Tying  Ligature  after  Trans- 
fixion. 


Fig.   18. —  Passing  Ligature  Beneath  Artery, 


THE  TREATMENT  OF  WOUNDS 


41 


deligated  in  the  usual  manner,  a  means  by  which  much  loss  of  blood 
may  be  obviated.  Large  blood  vessels  are  best  tied  in  their  continuity- ; 
the  vessel  is  exposed,  separated  from  the  surrounding  tissue  by  blunt 
dissection  and  a  ligature  is  carried  beneath  it  in  the  manner  shown  in 
Fig.  18 ;  the  vessel  is  doubly  deligated  and  divided  between  the  liga- 
tures. 

When  bleeding  is  controlled  by  ligature  en  masse,  the  vessels  are 
not  isolated,  but  the  area  to  be  divided  is  transfixed  by  a  pedicle 

needle  (Fig.  19)  and  firmly  deli- 
gated; a  measure  used  for  the 
control  of  bleeding  from  the 
omentum,  broad  ligament  (sal- 
pingectomy, excision  of  ovarian 
cyst,  hysterectomy),  mesentery, 
hilum  of  kidney,  etc. 

The  arrest  of  Needing  hy  tor- 
sion consists  of  twisting  the  end 
of  a  divided  blood  vessel  b}^ 
means  of  the  affixed  forcipres- 
sure  (Fig.  20)  ;  this  measure  is 
not  without  danger  of  secondary 
hemorrhage,  unless  applied  onl}^ 
to  vessels  of  small  caliber. 
Angiotripsy  is  a  term  applied  to 
the  crushing  of  the  ends  of  ves- 
sels, either  by  torsion  or  by  com- 
pression. 

Hemostasis  hy  means  of  pres- 
sure ivith  sterile  gauze  is  em- 
ploA'ed  during  operations ;  it 
will  be  found  very  satisfactory 
for  the  control  of  capillary  oozing.  Complete  capillary  hemostasis  is 
especially  desirable  in  plastic  surgery,  as  even  moderate  trickling  of 
blood  beneath  transplants  may  be  responsible  for  failure  in  healing. 
Practical  dryness  of  operation  wounds,  after  all  of  the  ends  of 
the  divided  blood  vessels  have  been  obliterated,  may  be  achieved  by 
the  application  of  firm  pressure  b}^  means  of  sterile  gauze  wet  with 
warm  (110°F.  43.33°C.)  physiological  salt  solution,  maintained  for 
from  ten  to  fifteen  minutes.     Persistent  oozing  from  bone,  especially 


Fig.  19. —  ]\roDERx  Pedicle  Xeedle  Held 
IN  Needle  Holder. 


42 


WOUNDS 


the  emissaries  of  Santorini,  may  be  controlled  by  the  application  of 
sterile  wax.* 

Iodoform  gauze  tamponade  is  used  to  arrest  bleeding  from  large 
cavities,  especially  when  these  are  the  outcome  of  the  breaking  down 
of  necrotic  tissue ;  it  is  also  used  'for  packing  fresh  wounds  made  in 
acutely  inflamed  tissues.  The  capillarity  of  the  gauze  mechanically 
prevents  iodoform  intoxication. 

Arrest  of  hemorrhage  in  hemophiliacs  is  at  times  attended  wdth 
considerable  difficulty.  Hemophilia  may  be  defined  as  a  tendency  to 
spontaneous  or  excessive  trau- 
matic bleeding;  it  is  generally 
regarded  as  the  outcome  of  a 
lessened  coagulability  of  the 
blood,  together  with  a  peculiar 
lack  of  tonicity  —  rather  than 
anatomical  change  —  on  the 
part  of  the  walls  of  blood 
vessels,  or  a  dilatation  of  the 
vascular  system,  due  to  vaso- 
motor influences.  Sahli^  re- 
gards the  condition  as  an  heredi- 
tary failure  of  activity  on  the 
part  of  the  protoplasm  of  the 
formed  elements  of  the  blood, 
the  tissue  cells,  and  the  blood  vessel  cells,  in  the  production  of  co- 
agulation producing  substances,  mainly,  thrombogen  (thrombokinase), 
that  is  to  say,  there  is  a  disturbance  in  the  production  of  fibrin 
ferment. 

There  is  no  doubt  hut  that  heredity  is  an  important  element  in  the 
disease.  Lossen",  who  studied  207  members  of  a  family  covering  four 
generations,  states  that  the  disease  is  transmitted  by  the  mother, 
though  she  herself  has  not  the  affliction.  The  males  who  inherit  the 
disease  from  the  father  through  an  exempt  mother  do  not  transmit 
it  when  they  marry  healthy  women. 

Spontaneous  bleeding  occurs  from  the  mucous  membranes  of  the 
nose,  mouth,  gut,  and  bladder.     "When  bleeding  occurs  in  the  joints 


Fig.  20. —  Torsion  op  an  Artery. 


"Horsley's  wax  is  composed  of  7  parts  of  hoeswax  and  1  part  each  of  sweet 
oil  and  salicylic  acid.  It  should  be  kept  in  a  wide-mouthed  jar  submerfjed  in  an 
antiseptic  solution.     It  is  pinched  off  and  kneaded  for  use  when  required. 


THE  TKEATMENT  OF  WOUNDS  43 

it  is  a  very  serious  affliction.  Slight  trauma  to  the  skin  or  to  mucous 
membranes,  sucli  as  needle  pricks,  small  cuts  or  tears  of  the  fingers, 
irritation  of  the  gums  while  cleansing  the  teeth,  or  a  wound  after 
tooth  extraction,  frequently  leads  to  profuse  hemorrhage,  lasting 
intermittently  for  days  and  weeks,  though  death  usually  occurs  in  a 
few  days. 

The  ■  hleeding  is  best  treated  by  superficial  application  of  the 
thermocautery  and  firm  iodoform  gauze  tamponade.  Sterile  gauze 
moistened  with  adrenalin  solution  may  be  used  in  place  of  iodoform 
gauze. 

Gelettin  is  regarded  as  a  valuable  remedy  in  the  bleeding  of  hemo- 
philiacs, its  virtue  lying  in  its  ability  to  increase  the  coagulability  of 
the  blood ;  this  substance  is  used  locally  in  the  form  of  a  10  per  cent 
solution  heated  to  the  temperature  of  110°F.  (43.3°C.)  with  which 
g'auze  is  soaked,  and  used  as  a  compress ;  or  the  solution  may  be  injected 
into  a  joint.  The  same  solution  may  be  injected  into  the  circulation 
subcutaneously  in  the  region  of  the  breast  or  into  the  abdominal  wall, 
making  a  daily  injection  of  40  c.cm.  at  a  temperature  of  101°F. 
(37°C.),  until  the  bleeding  ceases;  for  the  purpose,  the  gelatin  is  dis- 
solved in  physiological  salt  solution ;  its  use,  however,  is  not  without 
danger,  because  of  the  difficulties  attendant  upon  sterilization.  Before 
using,  the  preparation  should  be  subjected  to  carefully  made  tests, 
including  control  injections  into  animals,  as  gelatin  is  likely  to  contain 
tetanus  bacilli. 

The  fibrin  ferment  in  the  blood  mau  be  increased  by  the  intravenous 
injection  of  from  10  to  20  c.  cm.  of  fresh  human  or  horse  blood 
serum.  The  same  substances  maj^  be  used  locally  by  means  of  gauze 
tampons. 

Natural  hemostasis  is  the  process  by  which  spontaneous  arrest  of 
hemorrhage  takes  place.  The  diameter  of  the  lumen  of  the  blood  ves- 
sels is  lessened  by  contraction  of  its  circular  fibers  and  the  vessel  is 
drawn  away  from  the  w^ound  surface  by  virtue  of  its  elasticity;  capil- 
laries are  closed  by  the  swelling  of  their  endothelium ;  blood  is  effused 
into  the  space  contiguous  to  the  contracted  and  shortened  blood  vessel 
and  undergoes  coagulation.  In  addition,  coagulation  of  blood  takes 
place  within  the  lessened  lumen  of  the  blood  vessel. 

When  blood  vessels  are  ligatured,  their  inner  walls  are  brought  in 
contact;  the  application -of  the  ligature  crushes  or  divides  the  muscu- 
laris  and  much  the  same  process  takes  place  as  occurs  in  natural 
hemostasis,  though  the  internal  clot  is  formed  when  the  internal  coat 


44  WOUNDS 

is  simply  approximated.  The  same  phenomenon  occurs  when  blood 
vessels  are  crushed  as  in  contused  and  lacerated  wounds,  indeed, 
hemorrhage  from  large  blood  vessels  may  be  arrested  in  this  way; 
however,  lessening  of  blood  pressure  due  to  shock  is  a  factor  that  must 
be  taken  into  account  in  this  connection,  and  unless  more  staple  means 
of  permanent  control  of  hemorrhage  is  employed  in  the  interim,  the 
resumption  of  normal  blood  pressure  is  likely  to  be  attended  with 
secondary  hemorrhage. 

There  is  no  doubt  that  death  from  hemorrhage  is  not 
infrequently  obviated  by  the  lessening  of  blood  pressure  that 
goes  with  SHOCK,  au  occurrence  that  may  quite  properly  be  regarded 
as  a  conservatism  on  the  part  of  Nature;  one  that  must  not  be  disre- 
garded to  the  extent  of  indiscriminate  administration  of  stimulants 
before  proper  precautions  have  been  taken  to  obviate  the  recurrence 
of  bleeding. 

Permajient  hemostasis  is  the  outcome  of  organization  of  the  blood 
clots,  contraction  of  the  walls  of  the  blood  vessels,  and  of  union  of 
their  opposed  elements,  causing  thereby'  complete  occlusion  of  lumen. 

Death  from  hemorrhage  is  believed  to  be  due  to  an  absence  of  blood 
in  the  left  ventricle  which,  no  longer  receiving  blood  from  the  veins, 
cea.-;es  action  in  systole,  i.  e.,  there  is  no  blood  to  dilate  the  ventricle 
into  diastole. 

Hemorrhage  is  most  dangerous  in  children,  who  will  succumb  after 
the  loss  of  relatively'  small  quantities  of  the  circulating  fluid. 
Children  at  the  age  of  one  year  have  died  after  losing  250  c.  cm.  of 
blood,  while  adults  survive  the  loss  of  one  half  of  the  total  quantity  of 
blood  in  the  body.  Calculations  in  this  connection  lack  accuracy,  as 
many,  factors,  such  as  arterial  and  cardiac  disease,  the  preexistence  of 
exhausting  diseases,  length  of  time  occupied  during  an  operation,  and 
the  rate  at  which  the  blood  is  lost  (not  allowing  for  compensatory 
adjustment)  enter  into  consideration,  though  in  a  general  way  it 
ma}'  be  said  that  adults  survive  the  loss  of  blood  to  about  one  twenty- 
fifth  of  the  weight  of  the  body. 

The  quantitative  loss  of  Hood  is  replaced  by  extraction  of  fluids 
from  the  tissues,  which  accounts  for  the  distressing  thirst  in  these 
cases.  After  a  short  period  of  time  leukocytosis  increases  (post 
h.morrhagic  leukocytosis),  soon  to  be  followed  b}-  the  replacement  of 
red  blood  corpuscles.  Complete  restoration  of  the  lost  blood  depends 
of  course  upon  the  causative  factor  as  regards  the  bleeding.  In  a 
general  way  it  may  be  said  that,  in  cases  of  moderate  severity,  two 


THE  TREATMENT  OF  WOUNDS 


45 


to  five  da3's,  and,  in  severe  cases  of  loss  of  blood,  from  fourteen  to 
thirty  days  are  required  for  complete  restitution  to  the  normal. 

Venesection  or  therapeutic  bleeding  belongs  more  to  histor}^  than  to 
modern  surgery ;  it  is  still  emploA'ed,  however,  for  the  purpose  of  tem- 
porary relief  of  certain  conditions,  such  as  overloaded  heart,  uremia  or 
eclampsia,  etc.,  with  the  view  of  causing  a  substitution  of  corpuscular 
elements  of  the  blood. 

For  the  purpose  the 
median  cephalic  vein  is 
usually  opened ;  the 
veins  of  the  forearm  are 
made  prominent  by  en- 
circling the  lower  por- 
tion of  the  upper  arm 
with  several  turns  of  a 
tourniquet,  w  h  i  c  h  is 
drawn  sufficiently  tight 
to  obstruct  return  cir- 
culation, care  being 
taken  not  to  interfere 
with  the  arterial  flow  of 
blood,  a  contingenc}' 
easily  obviated  by  not- 
ing the  pressure  of  the 
radial  pulse. 

The  cephalic  vein  is 
selected  for  opening  be- 
cause of  its  prominence 
and  because  cutaneous 
nerves  are  not  injured 
when     the     incision     is 

made  in  this  region.  After  the  area  of  attack  has  been  cleansed  in  the 
usual  manner  (p.  86),  the  vein  is  held  in  position  by  the  thumb  of  the 
left  hand,  and  an  incision  about  1  cm.  in  length  is  made  obliquely  to  its 
long  axis,  exposing  the  vein,  which  is  then  opened  with  the  knife  to 
the  extent  of  about  one-third  its  circumference  (Fig.  21).  Blood  to 
the  amount  of  1  per  cent  of  the  body  weight  may  be  safely  dis- 
charged, after  which  the  constricting  tourniquet  is  removed  and  a 


Fig.  21. —  Vexesectxx. 


46  "WOUNDS 

sterile  pad  applied  over  the  wound  held  in  place  by  light 
pressure. 

"With  slight  skill  the  vein  may  be  punctured  through  the  skin  by 
means  of  the  hollow  needle  employed  for  the  withdrawal  of  blood  for 
diagnostic  purposes.  An  ordinary  suction  syringe  permits  of  accuracy 
in  manipulation,  especially  as  regards  quantity  of  depletion. 

When,  for  special  reasons,  it  becomes  necessary  to  open  the  external 
jugular  vein,  central  pressure  is  made  by  placing,  immediately  above 
the  clavicle,  a  compress  which  is  held  in  place  by  a  bandage  carried 
under  the  opposite  axilla.  Pressure  is  then  applied  to  the  vessel  above 
the  point  of  proposed  incision,  and  the  vein  is  opened  at  a  right  angle 
to  the  fibers  of  the  platysma  myoides  muscle.  The  opening  in  the 
vein  must  be  closed  by  pressure,  before  the  compress  above  the 
clavicle  is  removed,  in  order  to  obviate  the  entrance  of  air  into  the 
circulation  (air  embolism). 

The  constitutional  symptoms  of  anemia  from  loss  of  blood  are: 
Pallor  of  the  skin  and  mucous  membranes,  pinched,  anxious  expres- 
sion of  countenance,  feeling  of  fatigue,  syncope,  restlessness,  vomiting, 
spots  before  the  eyes,  ringing  in  the  ears,  yawning  and  diminution  in 
volume  of  pulse.  Air  hunger,  cold  clammy  perspiration,  dilated 
pupils,  convulsions  and  involuntary  discharge  of  urine  and  feces  are 
symptoms  indicative  of  great  danger. 

The  treatment  of  acute  anemia  demands  prompt  action  in  order 
that  a  fatal  outcome  may  be  obviated ;  immediate  control  of  the  bleed- 
ing from  the  wound,  even  by  temporary  means  such  as  tamponade,  is 
indicated,  while  at  the  same  time  measures  directed  toward  raising  the 
blood  pressure,  increasing  the  quantity  of  circulating  fluid  and  stimu- 
lation of  the  heart's  action,  are  to  be  actively  employed. 

The  patient  is  placed  in  the  recumbent  position  with  the  head 
lowered,  the  limbs  are  elevated  and  partially  exsanguinated  —  for  a 
short  period  of  time  only  —  by  means  of  a  lightly  applied  v.  Esmarch 
elastic  bandage  (p.  35),  a  measure  that  lessens  the  area  through  which 
the  heart  is  called  upon  to  force  the  blood  (autotransfusion).  The 
patient  is  wrapped  in  warm  blankets,  subcutaneous  injections  of  a  10 
per  cent,  camphorated  oil  are  administered  and  warmed  brandy,  mixed 
with  salt  solution,  is  introduced  into  the  rectum.  If  consciousness  is 
not  lost  and  there  is  no  vomiting,  hot  coffee,  champagne,  brandy  and 
hot  water  may  be  given  by  the  mouth. 

In  menacing  cases  infusion  of  physiological  salt  solution  is  often 


THE  TREATMENT  OF  WOUNDS  47 

a  life  saving  measure,  and  lias  displaced  the  older  methods  of  the  intro- 
duction of  defibrinated  blood  into  the  circulation. 

The  technic  of  Diefenbach,  designed  to  obviate  the  unfavorable  con- 
sequences of  the  use  of  defibrinated  blood,  despite  rigid  asepsis  did 
not  prevent  the  occurrence  of  chills  and  rise  of  temperature  (so-called 
transfusion  fever,  together  with  d^'spnea,  c^^anosis,  hemoglobinuria, 
bloody  diarrhea,  and  unconsciousness.  A  fatal  outcome  ensued  in  not 
a  few  instances.  Serious  blood  changes  and  capillary  thrombosis  may 
be  regarded  as  the  cause  of  the  disturbances  mentioned ;  death  resulting 
from  cardiac  and  pulmonary  embolism. 

Death  may  be  attributed  to  two  causes  other  than  air  embolism: 
(1)  The  introduction  of  small  blood  clots  into  the  venous  circulation 
despite  careful  filtration  of  the  material,  a  danger  that  may,  perhaps, 
be  obviated  by  making  the  injection  into  the  radial  artery,  so  that  any 
emboli  in  the  fluid  ma}'  be  arrested  in  the  capillaries.  (2)  Even 
difibrinated  blood  contains  sufficient  fibrin  ferment  to  cause  dangerous 
coagulation  (v.  Bergmann^).  It  is  claimed  that  when  defibrinated 
blood  is  allowed  to  stand  for  ten  minutes  the  fibrin  ferment  undergoes 
a  chemical  change  rendering  it  inert. 

The  fibrin  is  removed  from  the  fluid  by  gravity  filtration.  The  resid- 
ual mass  of  fibrin  must  not  be  pressed  for  fear  of  forcing  fibrin 
ferment  or  other  coagulation  producing  substances  into  the  filtrate. 
The  infusion  is  made  very  slowly  (200  c.  cm.  —  6  oz. —  in  about  half 
an  hour)  into  the  median  cephalic  vein,  into  which  a  suitable  cannula 
has  been  introduced. 

As  the  infusion  is  made  with  the  view  of  replacing  lost  blood  its 
action  cannot  be  attributed  to  the  quantity  of  material  introduced 
but  is  believed  to  be  the  outcome  of  its  effect  upon  the  bone  marrow 
which  is  stimulated  into  blood  formation  (Morawitz^) . 

With  the  view  of  obviating  the  intoxication  due  to  the  introduction 
of  fibrin  ferment,  direct  or  immediate  tranfsusion  is  employed.  This 
measure  was  at  first  accomplished  by  means  of  a  cannula,  through 
which  the  blood  was  made  to  pass  en  route  to  the  recipient ;  it  was  soon 
discarded,  however,  because  of  the  danger  of  coagulation  of  blood  in 
its  lumen  and  consequent  embolism. 

A  modification  of  the  cannula  method  was  worked  out  by  Crile^° 
who,  as  the  outcome  of  painstaking  experimental  work,  submitted  a 
device  for  the  purpose  of  anastomosis,  by  which  the  intima  of  the  vein 
of  the  recipient  was  made  to  lie  in  contact  with  the  inner  coat  of  the 


48 


WOUNDS 


radial  artery  of  the  donor  during  the  time  the  blood  flowed  from  the 
latter  into  the  former. 

The  teclinic  of  the  procedure  shown  (Fig.  22)  is  attended  with  con- 
siderable difficulty,  though  modifications  of  certain  details  in  the  pro- 
cedure have  been  made  by  Biirger,"  Bemheim/-  Guillot/^  and  others, 
all  of  which  were  devised  in  the  interest  of  simplicity. 


Fig.   22. —  DixVGRAMs  of  Stages  of  End-to-End  Anastomosis  of   Two  Blood 
Vessels  by  the  Cannula  Method.     (As  modified  by  Crile  and  Hitchings.) 

a,  pulling  the  vein  through  the  cannula:  very  fine  pointed  forceps  may  be 
substituted  for  the  single  suture;  6,  cuffing  back  the  vein  over  the  cannula  with 
three  mosquito  hcmostats;  c,  the  vein  cuffed  and  tied  in  place  in  the  grove  next 
to  the  handle  of  the  cannula;  the  artery  is  ready  to  be  drawn  over  the  vein; 
d,  the  anastomosis  completed,  and  the  cannula  hemostat  removed;  the  artery  is 
tied  in  the  remaining  groove;  the  short  handle  of  the  cannula,  is  so  light  m 
■weight  that  it  does  not  cause  torsion  of  the  vessels  (Crile). 


THE  TREATMENT  OF  WOUNDS  49 

The  trauma  to  the  blood  vessels  with  its  objectionable  features,  con- 
sequent to  the  use  of  the  device  as  stated,  has  led  to  anastomosis  by 
sewing  only,  a  procedure  attended  with  great  technical  difficulties. 
The  method  shown  (Fig.  23)  is  the  outcome  of  the  experimental  work 
of  Carrel.^* 

Transfusion  of  blood  is  also  practiced  by  connecting  the  artery  of 
the  donor  to  the  vein  of  the  recipient  by  means  of  a  rubber  tube 
with  glass  end  connections  lined  with  a  coating  of  paraffin,  destined 
to  obviate  the  formation  of  clots  (Pope^"). 

When  direct  transfusion  is  made,  the  connection  between  donor 
and  recipient  is  maintained  for  about  thirty  minutes  or  until  the 
donor's  blood  pressure  falls  to  from  125-100  mm.  Hg. 

Direct  transfusion  is  attended  at  times  by  hemolysis.  Many  factors 
render  the  occurrence  of  hemolysis  unlikely,  the  chief  of  which  is  the 
use  of  blood  relations  for  the  purpose.  In  all  cases  the  necessary  tests 
should  be  made  in  this  connection  which  involves,  in  cases  of  shock 
from  loss  of  blood,  delay  that  is  perhaps  unwarranted. 

The  introduction  of  normal  blood  into  the  circulation  in  cases  of 
acute  anemia  may  be  satisfactorily  accomplished  by  the  so-called 
indirect  or  interrupted  methods  (summarized  by  Brenizer^®)  :  (a)  by 
needle  or  syringe,  and  (b)  by  means  of  a  receptacle  or  intermediary 
containing  anticoagulant. 

The  technic  of  the  needle  and  syringe  method  consists  in  withdraw- 
ing blood  from  the  cephalic  (or  other)  vein  of  the  donor  by  means  of 
a  needle  and  sj'ringe  and  injecting  it  into  the  cephalic  vein  of  the 
recipient  which  is  punctured  with  a  second  needle. 

Brenizer^®  regards  the  method  in  which  an  anticoagulant  is  used  as 
the  most  useful.  Of  the  various  agents  employed  sodium  citrate  would 
seem  to  meet  best  the  indications.  In  this  method  the  blood  is  with- 
drawn from  the  cephalic  vein  of  the  donor  into  a  sterile  receptacle 
and  thoroughly  mixed  with  sodium  citrate  in  the  proportion  of  one 
part  of  a  2  per  cent  solution  of  the  citrate  to  ten  parts  of  blood. 
This  makes  a  0.2  per  cent  solution  of  citrate  with  blood  or  a  solution 
containing  one  grain  of  citrate  in  500  c.  cm.  of  blood. 

The  cephalic  vein  of  the  recipient  is  needled  in  the  direction  of  the 
blood  stream  and  the  citrated  blood  is  allowed  to  flow  into  the  vein 
in  the  manner  described  in  connection  with  the  infusion  of  salt  solu- 
tion (p.  51). 

Taking  into  account  the  fallacies  liable  to  attend  the  teehnic,  the 
delay  in  finding  a  suitable  donor,  the  danger  of  biochemical  changes 


50 


"WOUNDS 


Fig.  23.— Diagrams  op  Stages  of  Exd-to-End  Anastomosis  of  Two  Blood 
Vessels  by  the  Suture  Method  (Carrel). 
a,  Method  of  placing  the  three  stay  sutures:  they  are  equidistant  and  pass 
through  the  entire  thickness  of  the  vessel  walls;  b,  the  stay  sutures  tied,  and 
the  lower  angle  retracted  by  the  weight  of  a  hemostat;  c,  placing  the  over  and 
over  continuous  suture  between  two  of  the  stay  sutures:  the  vessels  are  lifted 
by  the  upper  sutures  in  the  hands  of  an  assistant,  so  as  to  make  an  angle  be- 
tween the  vessels:  this  permits  easy  sewing  with  the  straight  needle;  d,  the 
anastomosis  completed   (Crile). 


THE  TREATMENT  OF  WOUNDS 


51 


in  the  transfused  fluid,  direct  transfusion  of  blood  in  cases  of  acute 
anemia  from  liemorrhage  may  be  regarded  as  a  useful  measure  only 
when  employed  under  conditions  which  obviate  the  dangers  stated. 
In  many  instances  it  will  be  found  necessary  to  resort  to  the  use  of 
normal  salt  solution  in  this  class  of  cases.  This  viewpoint  would 
seem  to  be  shared  by  Sencert^'  and  his  associates.  With  regard  to 
direct  transfusion  by  anastomosis,  it  must  not  be  forgotten  that  the 
method  furnishes  the  recipient  with  the  much  needed  blood  pressure 
derived  from  the  donor. 


Fig.   24. —  Method  of  Intravenous  Administration   of  Salt   Solution   with 

Needle  (Gwathmey). 

Normal  salt  solution*  is  introduced  into  the  "body  iniravenously, 
sulcutaneously,  or  into  the  colon.  In  menacing  cases  the  use  of  the 
intravenous  method  is  indicated. 

The  preparation  of  a  sterile  0.9  per  cent  salt  solution  is  a  simple 
matter.  If  a  properl}-  prepared  solution  is  not  constantly  on  hand,  as 
obtains  in  the  operating  rooms  of  large  hospitals,   the  commercial 


*  Solutio    nutrii    chlorati   physiologica,    according    to    the    new    Pharmacopoeia, 
consists  of  the  following:     ISTatr.  chlorid.  8.0,  natr.  carbonat.  0.15,  water  991.85. 


52 


WOUNDS 


sodium  chlorid  may  be  mixed  with  distilled  water  and  boiled  for  one 
hour  in  a  glass  container.  For  convenience,  and  with  the  view  of 
obviating  the  presence  of  foreign  material,  a  carefully  filtered  con- 
centrated solution  of  chemically  pure  sodium  chlorid  is  made  and 
placed  in  tubes  similar  to  those  emplo^^ed  for  drainage  tubes,  etc.  A 
sufficient  amount  of  the  concentrated  solution  is  placed  in  a  single 
tube  to  correspond  to  the  amount  of  soluble  constituents  necessary 
to  give  the  required  strength  to  two  quarts  (2L)  of  water. 

Infusion  directly  into  the   circulation,  by  way   of   the  veins,    is 
accomplished  as  follows: 


Fig.  25. — -Xeedle  Introduced  ixto  Veix  (Gwatlimey). 


Venestasis  is  produced  in  the  manner  described  (p.  34).  The 
vein  (median  basilic)  may  be  punctured  through  the  skin  with  a 
large  h5T)odermie  needle  or  one  of  the  many  needles  devised  for  the 
administration  of  salvarsan  may  be  used.  As  shown  in  the  illus- 
tration (Fig,  21),  the  distended  vein  is  steadied  by  the  fingers  of  the 
left  hand  and  the  needle  made  to  traverse  the  skin  to  the  side  of  the 
vein;  after  the  skin  is  punctured,  the  point  of  the  needle  is  made  to 
enter  the  lumen  of  the  vein  (Figs.  24  and  25). 

The  needle  is  introduced  into  the  vein  before  it  is  connected  with 
the  salt  solution  container.  The  operator  assures  himself,  by  the  flow 
of  blood  from  the  proximal  end  of  the  needle,  that  the  lumen  of  the 


THE  TKEATMENT  OF  WOUNDS  53 

vein  is  invaded.  The  portion  of  salt  solution  in  the  rubber  connect- 
ing tube  having  been  lowered  in  temperature  by  radiation  of  heat,  is 
permitted  to  flow  until  the  warmer  liquid  higher  up  makes  its  appear- 
ance; a  measure  w^hich  also  causes  air  bubbles  to  be  expelled.  "With 
the  salt  solution  freely  flowing,  connection  with  the  needle  is  made, 
the  band,  constricting  the  upper  arm  is  loosened,  and  the  infusion 
proceeds.  It  may  be  necessary  at  times  to  incise  the  skin  slightly  and 
puncture  the  exposed  vein. 


Fig.  26. —  Openixg  Vein  tor  Infusion  ;  Peripheral  Ligature  Held  by 
Forcipressure;  Loop  Steadying  Vein  (Gwathmey). 


As  repeated  infusions  are  often  necessary,  the  method  described 
would  seem  to  be  a  desirable  one;  however,  as  the  flow  of  salt  solution 
through  the  narrow  lumen  of  the  needle  is  very  slow,  and  the  indica- 
tion in  the  larger  number  of  instances  is  to  supply  pressure  to  the 
failing  circulation,  most  cases  would  seem  to  call  for  infusion  by  the 
dull  cannula  method. 

When  salt  solution  is  infused  hy  means  of  of  the  cannula  the  vein  is 


54  WOUNDS 

exposed  by  an  oblique  incision,  dissected  from  its  contiguous  tissues, 
deligated  peripherally,  and  opened  with  fine,  sharp  pointed  scissors 
(Fig,  26),  The  cannula  is  introduced  and  held  in  place  by  a  second 
ligature  tied  in  a  half  knot  (Fig.  27),  which  is  used  as  a  central 
ligature  when  the  camiula  is  removed. 

In  either  method,  from  one  to  two  quarts  (2  L.)  of  the  solution  is 
permitted  to  flow  into  the  circulation.  The  procedure  is  followed  by 
'the  application  of  an  aseptic  dressing. 

The  infusion  may  be  repeated  as  often  as  two  or  three  times  in 


r - ^ 

1 

^. 

L.: 

Fig.  27. —  Cannula  in  Place  and  Connected  with  Container   (Gwathmey). 


twenty-four  hours,  two  quarts  (2  L.)  being  used  at  a  session.  It 
would  seem  wise  to  employ  the  dull  cannula  and  ligature  method  at  the 
first  session,  repeated  infusions  being  made  by  subcutaneous  needle 
puncture. 

Subcutaneous  infusion  (Jiypodermoclysis)  consists  in  the  injection 
of  salt  solution  beneath  the  skin.  Adrenalin  may  be  added  to  the 
solution. 

Absorption  from  heneath  the  skin  is  necessarily  slow,  and,  indeed, 
it  is  a  question  if  it  be  as  rapid  as  obtains  from  the  colon.  As  a  whole, 
it  may  be  said  that  it  is  the  least  frequently  indicated  of  the  three 


THE  TREATMENT  OF  WOUNDS 


55 


methods  of  administering  saline  solution.  For  the  purpose  a  con- 
tainer is  connected  with  a  large-sized  hollow  needle ;  the  skin,  after 
being  cleansed,  is  punctured,  and  the  fluid  is  permitted  to  enter  slowly 


Fig.  28. — •  Hypodermoclysis  (Kelly). 

the  subcutaneous  cellular  tissue  (Fig.  28).  The  pectoral  region,  the 
buttocks,  and  the  latissimus  dorsi  are  the  favorite  sites  of  injection. 
No  more  than  half  a  pint  (250  c.  cm.)  should  be  introduced  in  one 


56  WOUNDS 

place.  The  skin  will  be  found  quite  tense  as  the  result  of  the  distention 
caused  by  the  entrance  of  the  fluid,  and  the  injection  of  a  greater 
quantity  may  lead  to  pressure  necrosis  of  the  surrounding  soft  parts ; 
indeed,  this  possibility,  even  with  proper  precautions,  is  sufficiently 
liable  to  occur  to  constitute  an  objection  to  the  method.  Considering 
that  circulation  is  necessary  to  absorption,  it  is  easy  to  see  how  the 
fluid  may  remain  in  the  region  of  its  introduction  without  entering 
the  circulating  fluid  for  a  considerable  period  of  time.  If  the  intent 
of  the  act  is  to  furnish  a  circulating  medium  to  a  depleted  perpheral 
circulation,  the  measure  may  be  said  to  fail  to  accomplish  the  pur- 
pose. The  temperature  of  the  fluid  should  be  about  110°F.  (43.33°C.). 
Massage  of  the  parts,  immediately  subsequent  to  the  injection,  favors 
absorption  of  the  fluid. 

The  introduction  of  saline  solution  into  the  colon  {enteroclysis) 
finds  its  rationale  in  the  assumption,  that,  in  the  class  of  cases  calling 
for  an  increase  in  volume  of  circulating  fluid,  the  blood  is  more  largely 
collected  in  the  vessels  of  the  abdomen,  and  that,  because  of  this,  it 
will  take  up  the  fluid. 

Enteroclysis  probably  occupies  a  position  between  venous  infusion 
and  injection  into  the  subcutaneous  tissues.  In  a  general  wa}', 
menacing  cases  call  for  venous  infusion ;  less  severe  cases  for  entero- 
clysis ;  and  moderate  cases  for  hypodermoclysis. 

After  cleansing  the  lower  bowel  by  enema,  the  fluid  is  made  to 
enter  the  bowel  through  a  rectal  tube  connected  with  a  container. 
A  gallon  (4  L.)  of  the  fluid  (to  which  adrenalin,  brandy,  etc.,  may  be 
added),  if  introduced  slowly,  may  be  permitted  to  enter  the  bowel  at 
one  sitting.  The  first  pint  (500  c.  cm.)  may  be  introduced  more 
rapidly.  The  patient  is  placed  on  the  left  side  and  the  foot  of  the  bed 
is  elevated  to  promote  the  influence  of  gravity.  The  container  should 
not  be  elevated  more  than  three  feet  above  the  level  of  the  anus. 

Following  operations  of  magnitude,  enteroclysis  by  the  drop  method 
may  be  employed  to  replace  the  liquid  of  the  body.  The  number  of 
drops  introduced  per  minute  is  readily  controlled  by  graduated 
pressure  upon  the  rubber  connecting  tube. 

It  is  not  necessary  to  await  the  clinical  manifestations  of  shock 
before  the  employment  of  enteroclysis ;  its  use  immediately  following 
severe  injuries  or  extensive  operative  procedure  may  be  regarded  as 
a  life  saving  measure. 

The  infusion  of  salt  solution  in  cases  of  failing  heart  action,  the 
outcome  of  prolonged  narcosis,  is  a  valuable  measure,  as  is  its  employ- 


THE  TREATMENT  OF  WOUNDS  57 

inent  iii  postoperative  vomiting.  Its  action  as  a  diuretic  is  of  aid  in 
favoring  tlie  elimination  of  poisons,  such  as  illuminating  gas,  urea, 
and  the  products  of  general  infections.  Kiittner^^  adds  oxygen  to  the 
infusion  with  seeming  benefit.  Kulin'''  regards  the  addition  of  sugar 
to  the  solution  as  a  preventive  of  thrombosis,  on  the  theor^^  that  sugar 
prevents  the  formation  of  fibrin  (dextrose  4.0,  sodium  saccharatc  0.04, 
potass,  saccharate  0.04,  sodium  chlorate  0.85,  aq.  dest.  100.0). 

Following  the  arrest  of  hemorrhage,  the  subsequent  care  and  treat- 
ment of  wounds  involves  prevention  of  the  entrance  of  pernicious 
influences  and  the  creation  of  conditions  most  favorable  to  healing. 

Wounds  must  be  guarded  against  the  entrance  of  infective 
BACTERIA  and  protected  from  mechanical,  chemical,  and  thermic 
injury.  The  invasion  of  operative  wounds  b}^  bacteria  is  prevented 
by  the  rigid  exercise  of  aseptic  measures,  while,  on  the  other  hand, 
every  accidentally  inflicted  wound  is  to  be  regarded  as  infected  simul- 
taneously with  its  infliction,  and  prone  to  subsequent  contamination 
by  pus-producing  and  putrefactive  organisms,  of  a  character  standing 
in  a  causative  relationship  to  serious  complications. 

Primary  wound  infection  is  rarely  aitendcd  tvith  serious  conse- 
quences, if  its  existence  is  taken  into  account  in  the  immediate  care 
and  treatment ;  for  instance,  a  contused  or  lacerated  W' ound  presents 
a  less  menacing  condition  of  affairs  in  this  connection,  if  it  be  at  once 
given  the  same  treatment  as  obtains  in  operative  wounds.  Much  more 
serious  is  the  occurrence  of  secondary  infection.  If  the  wound  be 
handled  with  the  fingers,  wiped  with  unclean  rags,  probed  with  non- 
sterile  instruments  or  fingers,  or  washed  with  waterj^  solutions  at  the 
same  time  as  the  contiguous  skin,  more  serious  secondary  infection 
may  occur  than  would  have  obtained  had  the  wound  been  left 
undisturbed. 

Not  the  least  mportant  problem  in  the  treatment  of  accidentalhj  inflicted 
wounds  is  to  obviate  the  furtlier  development  of  primary  infection  and  prevent 
the  occurrence  of  secondary  infection. 

The  menace  involved  in  meddlesome  manipulation  of  accidental 
wounds  has  led  to  the  creation  of  the  "first  aid  package,"  which  con- 
sists of  a  sterile  compress  sewed  to  a  retention  bandage,  ingeniously 
packed  so  as  to  permit  of  its  being  opened  and  applied  to  a  wound, 
without  coming  in  contact  with  the  fingers.  This  device  was  first  used 
in  the  army  of  Holland,  and  later  develojoed  into  a  measure  of  great 
usefulness  by  the  American  army,  where  the  men  are  carefully 
instructed  with  regard  to  its  application, 


58  WOUNDS 

During  the  immediate  subsequent  treatment  the  "first  aid"  com- 
press is  not  disturbed,  but  may  be  covered  with  an  additional  layer  of 
sterile  gauze,  whilst  the  contiguous  skin  is  shaved,  washed,  and  disin- 
fected. When  wounds  are  small  or  are  located  in  portions  of  the  body 
that  are  difficult  to  cleanse,  it  is  best  to  subject  the  contiguous  area  of 
skin  to  dry  shaving,  followed  by  the  application  of  tincture  of  iodin. 

A  WOUND  THAT  HAS  NOT  BEEN  SUBJECTED  TO  MEDDLESOME  MANIPULA- 
TION, AND  THAT  HAS  BEEN  TREATED  IN  THE  MANNER  STATED,  IS  VERY 
UNLIKELY  TO  DEVELOP  INFECTION. 

Mechanical  irritation  should  he  carcfulhj  avoided;  forcible  manipu- 
lation which  would  interfere  with  the  process  of  healing  is,  of  course, 
rarely  indulged  in ;  however,  very  moderate  mechanical  trauma,  sucli 
as  muscle  contraction,  separation  of  the  edges  of  the  wounds,  or  the 
removal  of  dirt  by  friction  or  scraping,  will  sufficiently  lessen  the 
resistance  of  the  wound  surfaces  to  produce  conditions  favorable  to 
the  development  of  infection. 

Gentle  manipulation  and  firm,  even  application  of  the  protective 
dressing  are  important  measures  toward  the  prevention  of  mechanical 
irritation. 

Chemical  and  thermal  irritation  of  wound  surfaces  are  the  outcome 
of  old-fashioned  methods  of  wound  treatment,  which  lessen  the  natural 
bactericidal  capacity  of  the  tissues  and  create  conditions  favorable  to 
infection. 

In  the  time,  not  long  gone  into  history,  when  it  was  first  realized  that 
Avound  infection  was  the  result  of  bacterial  flora,  radical  measures  of 
relief,  such  as  the  application  of  the  cautery,  mineral  acids,  zinc  chlorid, 
etc.,  were  indulged  in  with  the  view  of  destroying  the  enemy.  It  is  true 
the  enemy  was  destroyed,  but  so  were  the  tissues. 

For  this  reason  cauterization  is  justifiable  only  when  it  is  prohahle  that 
a  highly  virulent  infective  agent  has  been  introduced  into  a  localized  area  of 
the  body,  and  its  immediate  destruction  may  be  accomplished,  such  as  an 
injury  received  by  the  surgeon  while  operating  for  the  relief  of  glanders, 
anthrax,  etc.,  or  in  cases  of  snake  bite,  lyssa  or  tetanus. 

When  it  is  considered  that  virulent  bacteria  entering  the  human  body 
have  only  a  brief  period  of  incubation,  and  are  immediately  absorbed 
by  the  blood  and  lymph  currents,  cauterization,  in  order  to  be  effective, 
must  be  immediate  and  completely  destroy  the  focus ;  should  this  not 
obtain  cauterization  becomes  dangerous,  as  its  action  seals  the  wound 
and  the  discharge  of  exudate  is  interfered  with;  also  the  reactive 
irritation  favors  absorption.     For  these  reasons,  it  would  seem  best 


THE  TREATMENT  OF  WOUNDS  59 

IMMEDIATELY  TO  EXCISE,  WITH  THE  KNIFE,  THE  INFECTED  AREA  AND 
FOLLOW  THIS  BY  THE  INTRODUCTION  OF  A  LIGHT  TAMPON  WHICH  ABSORBS 
EXUDATE  AND  PROMOTES  DRAINAGE  OF  THE  PRODUCTS  OF  THE  REACTIVE 
INFLAMMATORY  PROCESS. 

Solutions  of  antiseptic  chemicals  are  less  inimical  to  the  vitality  and 
resistance  of  tissues,  in  proportion  to  their  dilution  (1 :10,000  corrosive 
sublimate,  2 :3  per  cent  carbolic  acid,  etc.),  and  so  are  they  proportion- 
ately less  effective  as  destroyers  of  bacteria.  Lavage  of  wound  sur- 
faces with  antiseptic  solutions  does  not  destroy  bacteria ;  the  solution 
may  remove  blood  clots  and  particles  of  foreign  substances,  but  it  does 
not  come  in  contact  with  the  bacteria  which  lie  within  the  wound, 
covered  with  a  layer  of  fibrin.  Most  antiseptics  form  a  chemical  com- 
bination with  albumin,  rendering  them  inert.  It  is  true  that  ultimately 
this  chemical  combination  is  dissociated,  but  the  proportion  of  anti- 
septic in  a  wound  is  never  sufficient  totally  to  destroy  the  bacteria ; 
whatever  destructive  effect  antiseptics  have  is  exercised  upon  the 
tissues  themselves;  especially  is  this  true  of  watery  solutions  which 
mechanically  distend  the  cellular  elements;  therefore,  antiseptic  solu- 
tions should  never  he  used  in  a  fresh  wound. 

The  use  of  antiseptics  when  infection  has  occurred  is  taken  up  under 
a  separate  head  (p.  252). 

Chemical  injury  is  best  avoided  by  removing  from  the  wound  sur- 
faces, with  the  thumb  forceps,  all  foreign  bodies,  hairs,  etc.  Blood 
clots  are  carefully  wiped  away  with  sterile  gauze.  Small  quantities  of 
normal  salt  solution  may  be  dripped  into  the  wound,  and,  together  with 
offending  material,  removed  with  a  sterile  wipe  moistened  with  the 
i^ame  solution.  A  moderate  quantity  of  3  per  cent  hydrogen  peroxid 
may  be  dripped  into  the  wound  from  a  saturated  wipe ;  this  substance, 
in  contact  with  the  blood  and  wound  secretion  (also  pus),  liberates 
free  oxygen,  causing  the  formation  of  a  white  foam,  which  slowly 
bubbles  out  of  the  wound,  mechanically  expelling,  in  a  very  gentle 
manner,  foreign  material.  Hj^drogen  peroxid  does  not  injure  the 
tissues  and  has  the  additional  advantage  of  controlling  capillary 
oozing.    Oxygen  does  not  affect  the  growth  of  bacteria  (HonselP*^). 

''Tlie  use  of  the  cautery  and  the  employment  of  antiseptics  in  the 
treatment  of  accidentally  inflicted  wounds  is  like  the  war  tactics  of  a 
commanding  officer  who,  in  order  to  destroy  the  enemy,  lays  waste 
his  own  country.  The  aseptic  treatment  which  has  replaced  the  older 
methods  in  the  care  of  wounds  accidentally  inflicted,  or  of  those  made 
by  the  surgeon,  is  destined  to  destroy  the  invading  enemy  by  sparing 


60  WOUNDS 

the  tissues,  thus  creating  conditions  under  which  the  enemy  cannot 
exist"  (Lexer-^). 

Conditions  favorahle  to  wound  healing  are  obtained  by  removing 
from  the  injured  surfaces  those  substances  favorable  to  the  growth  of 
bacteria.  Blood  clots,  necrotic  tissue  and  wound  secretion  form  favor- 
able culture  media  in  this  connection.  In  addition,  blood,  lymph,  and 
exudate  increase  tension,  thereby  forcing  into  the  surrounding  tissues 


A 

J- 

/ 

/ 

.:  ^ 

/ 

r 

/ 

1 

4 

K 

/ 

/ 

' 

1 

riG.  29. — Alternating  Dkep  and  Superficial  Sutures. 

infective  substances.  Consequently,  hemorrhage  must  be  completely 
arrested  and  all  blood  clots  must  be  removed ;  and  deep  pockets  should 
be  made  accessible  by  enlarging  the  wound  with  the  knife  or  by 
making  counteropenings.  Contused  and  lacerated  wound  edges  and 
surfaces  should  be  made  smocfth  with  knife  and  scissors  (dchridemcnt). 
The  condition  of  the  properly  prepared  wound  and  the  probability 


THE  TREATMENT  OF  WOUNDS 


61 


of  the  occurrence  of  inflammation  decide  whether  closure  by  suture 
or  tamponade  and  drainage  are  to  be  emplo^-ed. 

Incised  waunds  may  J)e  closed  hy  su- 
ture, as,  because  of  their  smooth  sur- 
faces, they  present  conditions  very  un- 
favorable to  the  development  of  infec- 
tion. 

Contused  or  lacerated  wounds,  how- 
ever, should  not  be  sutured  except  under 
special  conditions.  If  the  wound  sur- 
faces are  made  smooth,  and  its  edges  are 
not  too  heavily  infiltrated  with  exudate, 
closure  by  suture  may  be  practiced ;  in 

some  instances  portions  of  wounds  of  these  classes  may  be  lightly 
apposed  with  interrupted  sutures,  leaving  ample  space  for  the  dis- 
charge of  exudate.     Wounds  severely  contused  or  lacerated  are  best 


Pig.  30. —  Reef  Knot, 


Fig.  31. —  Suturk  Properly  Tied.     Knot  drawn  to  one  side. 


treated  by  the  open  method.     Contused  and  lacerated  wounds  are 
best  closed  with  interrupted  silk  sutures. 


62 


WOUNDS 


For  the  purpose  of  relaxing  tensimi,  deepl}^  placed  sutures  are 
employed  (Fig.  29).  To  bring  in  close  apposition  the  edges  of  the 
skin,  the  suture  is  made  to  pass  through  the  integument  and  subcu- 
taneous tissues  of  the  border  of  the  wound,  at  a  distance  of  a  line  or 
more  from  them,  depending  upon  the  size  and  depth  of  the  wound ; 
the  suture  is  then  tied  by  a  reef  knot  (Fig.  30)  drawn  with  only  suffi- 
cient force  to  appose  the  borders  of  the  wound  without  puckering  the 
skin ;  the  knots  can  be  placed  on  alternate  sides  of  the  wounds  or  on 
the  same  side  only  (Fig.  31). 

For  the  purpose  of  introduction,  the  edges  of  the  wound  may  be 


Tig.  32. —  Method  of  Introducing  Suture. 


held  together  with  forceps  while  the  needle  is  being  passed  (Fig.  32). 
The  security  of  the  suture  depends  upon  the  kind  of  knot  employed 
in  the  J:ying. 

The  simple  reef  knot  (Fig.  30)  answers  the  purpose  very  well, 
though  for  additional  security  the  surgeon's  or  friction  knot  may  be 
used ;  this  knot  is  formed  hy  making  two  turns  of  the  suture,  instead 
of  one,  at  the  first  loop  (Fig.  33).  Under  no  circumstances  must  the 
suture  be  tied  with  a  granny  knot  (Fig.  34). 

Silver  wire  may  be  used  for  the  closure  of  wounds  of  soft  parts, 
though  it  is  more  commonly  emploj'ed  in  the  repair  of  bony  structures. 
Silver  wire  is  not  tied,  but  is  made  immobile  by  twisting  (Fig.  35). 

The  continuous  suture   (Fig.  36)   is  employed  to  unite  superficial 


THE  TREATMENT  OF  WOUNDS 


63 


Fig.  33. —  Surgeon  's  Knot. 


wounds;  it  is  also  used  in  making  anastomoses  between  serous  sur- 
faces (Fig.  37).  It  is  made  b}'  passing  the  needle  repeatedly'  through 
the  tissues,  and  after  fitting  the  suture  to  the  wound  tension,  confining 
the  ends  of  the  thread  by  means  of  a  final  suture  formed  by  uniting 

the  ends  made  by  division  close  to 
the  e^-e  of  the  needle,  with  the  end 
of  the  suture  remaining  at  the  op- 
posite side  of  the  wound. 

For   the   purpose   of   holding  to- 
gether large  wound  surfaces,  espe- 
cially when  there  is  great  tension, 
the   mattress  suture    (Fig.   38),   or 
sutures     passed     through     buttons 
{button  suture,  Fig.  39),  or  the  quilled  suture   (Fig.  40),  may  be 
used.     The  quilled  suture  is  slung  over  pieces  of  rubber  drainage 
tubing,  glass  rods,  or  slender  rolls  of  gauze. 

For  the  relief  of  harelip,  the  edges  of  the  w^ound  are  transfixed  by 
a  harelip  pin  and  the  wound  approximated  b^-  twisting  silk  in  the 
form  of  a  loop  around  the  protruding  portions  of  the  pin  (Fig.  41). 
This  method  may  be  used  in  other  situations  in  place  of  the  mattress 
or  button  suture. 

In  locations  where  it  is  particularly  de- 
sirable that  scarring  be  avoided,  the  sub- 
cuticular stitch  of  Halsted  (Fig.  42)  may 
be  used ;  the  suture  may  be  of  silk,  silver 
wire,  catgut  or  fine  silkworm  gut. 

Friable  tissue,  like  that  of  the  liver,  adi- 
pose tissue  or  tissue  easily  torn,  such  as 
muscle  fiber,  is  best  held  in  place  by  means 
of  square  sutures,  the  emplojTnent  of  which 
is  depicted  in  Fig.  43  A  and  B  ;  the  direction 
of  the  suture  depending  upon  w^hether  CA'er- 
sion  or  inversion  of  the  edges  of  the  wound  is  to  be  accomplished. 

All  sutured  wounds  should  be  protected  with  sterile  gauze;  the 
immediate  sealing  of  wounds  with  collodion,  plaster,  or  powdered 
antiseptics  interferes  with  the  discharge  of  wound  secretion  and  favors 
infection. 

Skin  sutures  'may  be  removed  at  the  end  of  from  five  to  eight  days. 
The  presence  of  non-absorbable  suture  material  in  the  skin  for  a  longer 


Fig.  34. —  Granny  Knot. 


64 


WOUNDS 


period  of  time  favors  the  migration  of  bacteria  from  the  contiguous 
skin. 

Buried  sutures  do  not  disturb  the  healing  of  aseptic  wounds.  If, 
however,  even  slight  infection  occurs,  small  fistulae  develop  and  the 
suture  material  is  ultimately  expelled,  together  with  serous  or  pur- 
ulent discharges. 

Suturing  of  intestine  differs  in  principle  from  that  involved  in  the 
apposition  of  wound  surfaces  generally;  in  the  latter  nicety  of  ad- 
justment of  the  wound  edges  is  desirable,  and  indeed  is  quite  essen- 
tial to  favorable  repair.  When 
portions  of  the  gut  are  to  be  united 
it  is  necessarj^  to  appose  broad  sur- 
faces of  serosa  by  inversion  of  the 
edges  of  the  wound,  for  which  pur- 
pose two  layers  of  suturing  are 
used ;  the  first,  a  continuous  or  in- 
terrupted suture  perforating  all  the 
layers  of  the  gut;  the  second,  an 


Fig.  35. —  Wound  Closed  with  Silver 
Wire. 


interrupted  suture  involving  only 
serosa  and  muscularis,  which  in- 
creases the  area  of  contact  and 
makes  more  secure  the  line  of  union 
(Figs.  44-45). 

Wounds  of  the  stomach  and  in- 
testine should,  in  each  instance,  be 
closed  by  two  layers  of  superim- 
posed    sutures,  ,   irrespective      of 
whether  the  trauma  has  perforated 
the  lumen  of  the  organ  or  simply  contused  or  lacerated  its  walls.     In 
instances  of  minute  perforation,  the  closure  by  means  of  purse  string 
suturing  may  be  employed  (Fig.  46). 

Tamponade  (gauze  packing)  of  wounds  is  employed,  with  the  view 
of  favoring  the  discharge  of  wound  secretion  and  of  preventing  the 
entrance  of  air  with  its  concomitant  aerobic  organisms  in  instances 
where  the  character  of  injury  (contusion  and  laceration)  or  exposure 
to  contamination  makes  healing  by  primary  union  improbable. 

The  sealing  of  the  -ports  of  entrance  of  gunshot  and  punctured 
wounds  with  dry  gauze  causes  absorption  of  wound  secretion  and  pre- 
vents the  entrance  of  infection  into  the  deeper  tissues,  giving  oppor- 
tunity for  undisturbed  repair. 


THE  TREATMENT  OF  WOUNDS 


65 


Fig.  36. —  CoxTixuotrs  Suture  Eeadt  to  be  Tied. 


For  the  purpose  of  aseptic  tamponade,  there  is  nothing  that  has 
taken  the  place  of  iodoform  gauze  (p.  69).     This  preparation,  after 

being  applied  to 
the  surface  or 
lightly  introduced 
into  the  deeper 
portions  of  wounds 
by  means  of  a 
sterile  instrument, 
becomes  rapidly 
saturated  with 
wound  secretion 
(capillary  drain- 
age). Blood, 
lymph,  exudate 
and  infectious  ma- 
terial (bacteria 
37. —  Continuous  Suture  Uniting  Serous  t   ,,    •  •         \ 

Surfaces.  ^^^^^  their  poisons) 


Fig. 


66 


WOUNDS 


-  •"■•^•^•^^j-iiJ^  - 


Fig.  38. —  Mattress  Suture. 


are  drawn  into  the  protective  dressing,  where  they  become  dry  and 
are  rendered  inert. 

The  antiseptic  action  of  iodoform 
■^_      -  ^.  _^%  _^  is  slight  and  does  not  influence  bac- 

terial flora  in  the  wound,  but  does 
destroy  the  microorganisms  absorbed 
into  the  gauze  impregnated  by  it,  so 
this  agent  properly  may  be  placed 
in  the  class  of  antiseptics. 

The  aseptic  quality  of  iodoform 
gauze  is  limited  to  the  surfaces  of  wounds,  whereas  its  effect  in  the 
deeper  layers  is  distinctly  antiseptic.  The  explanation  would  seem 
to  be  that,  contrary  to  the  general  belief,  the  action  of  this  agent  is 
not  the  result  of  the 
liberation  of  free 
iodin,  but  is  due  to 
the  formation  of  di- 
iodo-acetylid,  which 
however,  occurs  only 
in  the  relative  ab- 
sence of  oxygen,  a 
condition  of  affairs 
that  obtains  in  deep 
wounds.  The  poison- 
ous effects  of  iodo- 
form (iodoform  in- 
toxication) find  their 
rationale  in  this  ex- 
planation. On  the 
other  hand,  when 
iodoform  gauze  is  accessible  to  air  (surface  of  wounds),  the  separation 
of  the  poisonous  substance  does  not  occur  and,  as  already  stated,  only 
moderate  destruction  of  bacteria  takes  place. 

The  cavities  of  deep  wounds  should  be  carefully  lined  with  iodoform 
gauze,  after  which  the  hollow  spaces  may  be  filled,  under  light  pres- 
sure, with  sterile  gauze,  thus  obviating  the  introduction  of  too  much 
iodoform.  If  the  location  of  the  deepest  portion  of  the  wound  is 
unfavorable  as  regards  the  action  of  capillarity,  counter  opening  and 
drainage  are  to  be  employed. 

To  the  capillary  action  of  iodoform  gauze  may  be  attributed  the 


Fig.  39. 


Button  Suture;  Continuous  Suture 
Tied. 


THE  TREATMENT  OF  WOUNDS 


67 


rapid   diminution    of   bacterial   flora   and  the   early   subsidence    of 
infected  wounds. 

Bacterial  flora  rapkllij  increases  when  moist  antiseptic  tamponade 
is  applied  to  wounds.  The  use  of  wet  dressings,  kept  moist  b}'  super- 
imposed rubber  tissue,  is  to  be  deprecated;  despite  the  presence  of 
antiseptics,  bacteria  proliferate  in  the  wound,  invade  the  gauze  and 


Fig.  40. —  QriLLED  Suture. 

spread  over  the  macerated  tissues,  causing  the  development  of  pus- 
tules, furuncles,  etc.  It  is  not  a  figment  of  the  imagination  to  stig- 
matize this  condition  of  atl'airs  as  closel}'  allied  to  a  bacterial  incubator. 
Actual  observation  has  shown  that  the  confined  wet  dressing  lit- 
erally teems  with  bacterial  life,  which  slowly  ceases  when  the  mois- 
ture is  allowed  to  evaporate  to 
dryness. 

Wet     dressing     undoubtedly 
possesses  active  capillarity,  and, 
when  its  progressive  desiccation 
is   not   interfered   with   by   the 
presence    of    confining    rubber 
tissue,  it  may  be  regarded  as  me- 
chanically effective  in  removing 
bacteria  from  the  wound,  though 
its  usefulness  in  this  connection 
is  overshadowed  by  the  fact  that 
bacterial  flora  is  maintained  in  the  gauze,  engendering  danger  of  re- 
infection. 
For  this  reason  dru  tamponade  should  be  employed  in  the  treatment 


Fig,  41. —  Harelip  Pin  Suture. 


68 


WOUNDS 


of  freshly  infected  wounds,  and  the  unprotected  (without  impervious 
material)  moist  dressing,  used  only  in  wounds  in  which  the  secretion 
is  tenacious  or  the  expulsion  of  necrotic  areas  is  to  be  favored.  In 
the  latter  class  of  cases,  the  antiseptic  solution  dilutes  tenacious  secre- 


FiG.  42. —  Subcuticular  Suture. 


tion,  rendering  it  more  susceptible  to  the  mechanical  action  of  capil- 
larity, and  the  chemical  irritation  of  the  antiseptic  favors  exfoliation 
of  necrotic  tissue  (Carrel-Dakin  solution,  p.  246). 
Sluggish  granulating  wounds  are  best  cleansed  by  means  of  alcohol 


Fig.  43. —  Square  Suture. 
a.  Eversion  of  wound  edges.  b.  Inversion  of  wound  edges. 

compresses,  though  to  be  effective,  too  rapid  evaporation  of  the  alcohol 
must  be  prevented.  Impervious  confinement  of  the  alcohol  vapor  is 
still  more  objectionable,  because  of  danger  to  the  vitality  of  the  tissues. 
The  compress  may  be  covered  by  freely  perforated  rubber  tissue, 
which  would  seem  to  meet  the  indications. 


THE  TREATMENT  OF  WOUNDS 


69 


The  use  of  the  moist  carbolic  acid  compress  is,  perhaps,  most  in- 
dicative of  the  dire  effects  of  the  prolonged  application  of  antiseptics ; 
gangrene  of  the  wound  surfaces  and  surrounding  tissues  frequently 
result,  more  so  as  the  anesthetic  effect  of  the  agent  quite  masks  its  de- 
structive action,  which  may  reach  considerable  magnitude.  Indeed 
an  entire  limb  may  become  mummified  and  necrotic,  necessitating  am- 
putation. 

Moist  carbolic  acid  dressings  have  led  to  unfortunate  results  in  a 

sufficient  number  of  in- 
stances to  justify  the  cre- 
ation of  the  term  "  car- 
bolic acid  gangrene." 
The  use  of  iodoform 
'^  gauze  is  not  limited  to  the 
tamponade  of  infected 
wounds;  it  may  be  per- 
mitted to  remain  iii  situ 
in  serous  ca'S'ities  for  sev- 
eral days  with  the  view  of 
causing  the  development 
/  of  protective  adhesions, 
"^  and  is  used  for  the  pur- 
pose of  isolating  infected 
areas  of  serosa  from  con- 
tiguous healthy  cavities 
(abscess  of  the  lung,  or 
deep  seated  peritoneal  ab- 
/^scesses).  During  oper- 
ative attack  (intestinal 
anastomosis),  the  adja-' 
cent  peritoneum  may  be 
protected  by  temporary 
iodoform  gauze  tampon- 
ade. 

For  the  purpose  of 
availability,  iodoform  gauze  strips,  single  or  double,  of  a  width  of  8 
inches  (20  cm.)  will  meet  most  requirements. 

For  iamponade  of  large  cavities,  used  as  at  times  becomes  necessary 
in  abdominal  surgery,  the  device  of  v.  Mikulicz  is  useful;  a  large 
square  of  iodoform  gauze  is  introduced  by  engaging  its  center  in  the 


44. —  Intestinal  Suturing. 


a.  Inner  layer; 

fe.  Outer  layer;  inner  suture  is  tied; 
G.  Eelationship  of  the  edges  of  the  wound  after 
both  layers  are  tied. 


70 


WOUNDS 


Fig.  4.3. —  The  Inner  Continuous  Suture  Being 
Farther  Inverted  by  the  Outer  Interrupted 

Suture. 


depth  of  the  cavity ;  the  free  ends  are  allowed  to  project  beyond  the 
edges  of  the  wound  and  the  hollow  space  thus  formed  is  filled  with 
strips  of  sterile  gauze  (Fig.  47). 

The  sterile  gauze  strips  may  be  changed  frequently  without  disturb- 
ing the  outer  inverted 
tent  layer.  When  the 
outer  layer  is  ultimately 
removed,  its  edges  are 
folded  together  and 
firmly  grasped  with 
heavy  hysterectomy  for- 
ceps, by  means  of  which 
the  gauze  is  slowly 
twisted,  thus  separating 
it  from  the  surrounding 
tissues  with  but  slight 
trauma. 

The  length  of  time 
iodoform  gauze  is  al- 
lowed to  remain  in  situ 

depends  upon  the  condition  of  the  wound  and  the  purpose  for  which 
it  is  introduced.     From  fresh  wounds  it  may  be  removed  in  two  days, 

so  that  if  conditions 
warrant,  secondary 
sutures  may  be  em- 
ployed. In  cases 
where  there  has 
been  much  bleeding, 
as  in  hemophilia,  or 
when  large  sinuses 
have  been  opened, 
the  tampon  should 
remain  in  place  for 
two  weeks,  and 
should  be  removed 
onh'  after  the  gauze 
is  loosened  by  the  se- 
cretions of  the  new- 
FiG.  46. —  Purse  String  Suture  in  Internal  Perfora-    ,      t       ,      - 

TioN.  l3'  developmg  gran- 


THE  TREATMENT  OF  WOUNDS 


71 


ulatioii  tissue.  When  used  for  the  purpose  of  stimulating  the  spon- 
taneous obliteration  of  serous  cavities,  the  gauze  is  permitted  to  re- 
main in  place  for  one  week. 

In  wounds  that  are  the  site  of  tenacious  purulent  secretion,  and  in 
fresh  wounds  made  into  acutely  infected  tissues,  moist  gauze  (not  wet 
compresses  covered  with  rubber  tissue)  may  be  applied.  The  gauze 
used  for  these  purposes  may  be  moistened  with  3  per  cent  aluminum 
acetate  or  2  per  cent  boric  acid  solution;  also,  in  this  class  of  cases, 
it  is  not  amiss  to  apply  to  the  wound  gauze  smeared  with  ointments  of 


..<^ 


Fig.  r, 


-- MicKULicz  Tampon  in  sittt:  gauze  square  tilled  with  strips  op 

GAUZE. 


from  5  per  cent  to  8  per  cent  hydrarg.  oxid.,  or  10  per  cent  zinc.  oxid. 
alb.  rubbed  up  with  vaselin  or  lanolin,  or  borovaselin  and  Peru  bal- 
sam may  be  used.  This  prevents  adhesion  of  the  gauze  to  the  wound 
and  makes  possible  frequent  change  of  dressing  without  inflicting  pain. 
When  the  granulations  have  reached  the  level  of  the  skin,  epidermi- 
zation  may  be  stimulated  by  the  application  of  an  8  per  cent  scarlet  red 
ointment,  which,  however,  must  be  applied  only  to  the  edges  of  the 
wound;    first,  because  its  action  is  merely  that  of  a  stimulant  to 


72  WOUNDS 

epidermis,  and,  secondly,  because  a  wide  surface  of  contact  is  liable 
to  be  attended  with  poisoning. 

The  use  of  iodoform  gauze  is  not  without  its  disadvantages;  certain 
individuals  have  a  so-called  idiosjTicrasy  in  this  connection,  which 
expresses  itself  in  local  disturbances,  especially  on  the  skin  of  the 
hands  and  the  feet.  The  so-called  iodoform  eczema'  begins  at  the 
edges  of  the  wound  and  rapidly  spreads  over  the  contiguous  tissues, 
manifesting  itself  by  the  formation  of  an  erythema,  in  which  islands 
of  small  blebs  make  their  appearance.  The  affliction  is  attended  by  a 
very  irritating  itching.  The  s^Tuptoms  rapidly  recede  under  the 
application  of  zinc  ointment.  Patients  of  this  sort  should  be  informed 
of  their  idiosyncrasy,  so  that  they  may  escape  similar  attacks  in  the 
future. 

Constitutional  iodoform  'poisoning,  though  rare,  is  usually  the  result 
of  the  tamponade  of  deep  wounds  with  iodoform  gauze,  and  is  due  to 
absorption  of  the  chemical  products  already  described  (p.  66). 

Iodoform  poisoning  manifests  itself  by  nausea,  vomiting,  headache, 
tachycardia,  and,  in  severe  cases,  is  attended  with  cerebral  irritation, 
maniacal  delirium,  heart  failure  and  death.  The  urine  may  contain 
iodin  and,  in  fatal  cases,  hematuria  and  albuminuria  occur.  "When 
the  cause  of  the  condition  is  recognized  early,  prompt  recovery  follows 
removal  of  the  tampon.  In  severe  cases,  infusion  with  salt  solution  is 
to  be  employed. 

The  danger  of  iodoform,  intoxication,  and  the  offensive  odor  of  the 
agent,  has  led  to  efforts  to  replace  it  with  other  preparations ;  these 
may  be  divided  into  those  containing  iodin,  such  as  airol,  aristol, 
europhen,  isoform,  iodol,  iodolformal,  iodoformin,  loretin,  nosophen, 
novoiodin,  sozoiodol,  vioform,  etc.,  and  those  which  do  not  contain 
iodin,  like  alumnol,  amyloform,  dermatol,  thioform,  xeroform,  etc. 
Despite  the  claims  for  the  bactericidal  effects  of  these  various  substi- 
tutes, it  is  proper  to  state,  that  none  of  them  endows  the  tampon  with 
the  capillarity  and  hemostatic  quality  possessed  by  iodoform  gauze. 

Drainage  (other  than  by  capillarity)  should  aim  to  exercise  its  office 
at  the  most  dependent  portion  of  the  wound  area,  and  should  be  so 
arranged  that  it  be  not  interfered  with  as  a  result  of  the  posture  of 
the  patient,  which  would  render  futile  the  intent. 

Tuhe  drainage  is  emploj-ed  where  large  quantities  of  fluid  pus  are 
secreted ;  and  also  in  cases  of  extensive  trauma,  of  a  character  leading 
to  the  reasonable  inference  that  extensive  infection  is  liable  to  occur. 
It  is  rarely  used  in  clean  operative  wounds,  even  though  exudates  are 
likely  to  occur,  in  which  instances  other  drainage  material  is  emploj^ed. 


THE  TREATMENT  OF  WOUNDS 


73 


Glass  tuJ)ing  has  been  abandoned,  except  in  cases  of  tuberculous 
peritonitis,  and,  perchance,  for  drainage  of  empyema. 

Ruhher  tilling,  the  universal  material  of  choice,  should  be  of  suf- 
ficient caliber  to  meet  the  indications.  Tube  drainage  should  not  be 
indiscriminately  used,  but,  when  employed,  should  be  ample  for  the 

purpose.  The  quality  of  rubber  is  im- 
portant, as  sterilization  by  heat  dis- 
organizes tubing  of  inferior  grade. 

The  tubing  is  cut  to  the  desired  length, 
and  fenestrated  as  shown  (Fig.  48). 
When  cutting  the  fenestrae,  curved 
scissors  should  be  used  to  make  oval 
openings;  if  the  tube  be  bent  at  an  acute 
angle  and  triangular  pieces  cut  out  with 
straight  scissors,  the  resultant  fenestra 
is  diamond  shaped,  and  the  tube  is  liable 
to  kink  at  this  point  and  its  lumen  be- 
come obliterated.  In  order  to  prcA-ent 
the  tube  from  slipping  into  the  cavity  it 
is  draining,  a  safety  pin  is  fastened  to 
its  protruding  end  (Fig.  48).  The  pin 
should  be  pushed  through  the  side  of  the 
tube  —  not  across  its  caliber  at  the 
center  —  to  avoid  obstructing  the  dis- 
charge of  exudates. 

The  protrusion  of  the  tube  beyond  the 
skin  should  be  just  sufficient  to  allow  for 
the  safety  pin  and  a  pad  of  gauze  un- 
derneath the  latter,  thus  avoiding  oblit- 
eration of  the  end  of  the  tube  by  pressure 
from  the  protective  dressing.  The  ob- 
ject of  the  gauze  pad  is  to  prevent  con- 
tact of  the  pin  wath  the  wound. 

Tube  drainage  being  usually  em- 
ployed for  the  drainage  of  pus  cavi- 
ties, the  dressing  is'  changed  at  frequent  intervals;  this  is  impera- 
tive at  the  end  of  twenty-four  hours  following  operation,  as  the  trauma 
resulting  from  the  surgeon's  manipulations  gives  rise  to  a  certain 
amount  of  hemorrhage,  causing  the  formation  of  blood  clot,  which  is 
liable  to,  and  indeed  does,  invade  the  tube  and  thus  obstruct  its  lumen. 


Fig.    48. —  Kubber    Tube    Feme 

strated  and  safety  pin 

Attached, 


74 


WOUNDS 


Therefore,  the  tube  should  be  removed  at  the  end  of  twenty-four  hours, 
the  clot  from  tlie  lumen,  together  with  that  formed  in  the  wound 


Fig.  49A. —  Triplex  Eubbeb  Drainage  Tube. 


cavity,   expressed,   and  the  tube  boiled 
and  reinserted. 

In  cases  requiring  frequent  change  of 
dressing,  and  in  which  cleansing  of  the 
cavity  without  disturbing  the  drainage 
tube  is  desirable,  a  so-called  triplex 
drainage  tubing  may  be  advantageously 
employed.  The  tubing  is  made  of  pli- 
able rubber,  and  consists  of  three  small 
tubules  molded  together.  The  smaller 
lumen  acts  slightly  like  a  capillary  tube. 
This  arrangement  also  permits  of  the 
washing  of  a  cavity  through  one  of  the 
openings,  while  the  other  two  furnish 
ample  avenue  of  escape  for  secretions, 
and  allow  the  free  egress  of  the  cleansing  fluid, 
of  the  tube  is  shown  in  Fig.  49. 


Fig.  49B. —  Transverse  Sec- 
tion OP  Triplex  Rubber 
Drainage  Tube. 


A  transverse  section 


THE  TREATMENT  OF  WOUNDS 


75 


Silkworm  gut  is  employed  for  the  drainage  of  wounds  that  are 
attended  with  much  oozing,  with  the  view  of  draining  off  fluid  exu- 
date. It  is  rarely  used  when  infection  already  exists,  though  small 
abscesses  may  be  drained  by  means  of  this  agent. 

For  the  purpose  several  strands  of  silkworm  gut  are  employed,  the 


Fig.  50.  —  SiLKWORii  Gut 
Looped  for  Drainage  Pur- 
poses. 


Fig.    51. —  Catgut    Arranged 
FOR  Drainage. 


number  used  depending  upon  the  area  to  be  drained.  The  strands  of 
silk  worm  gut  are  looped  in  the  manner  shown  (Fig.  50).  The  loops 
spread  out  in  the  underlying  cavity,  and,  by  capillarity,  the  fluid 
exudate  is  caused  to  emerge  at  the  twisted  ends.     In  cases  of  moderate 


76  WOUNDS 

infection,  a  strand  at  a  time  may  be  removed  from  the  wound  as  the 
discharge  becomes  less,  thus  maintaining  drainage  in  proportion  to 
the  indications. 

Catgut  drai7iage  is  employed  in  much  the  same  way  as  is  silkworm 
gut;  it  is,  however,  never  used  in  the  presence  of  purulent  infection. 
It  has  the  advantage  of  being  absorbed,  and  need  not  be  removed. 
In  clean  cases,  its  employment  assures  an  avenue  of  escape  for  the 
fluid  exudates,  and  the  fact  that  it  is  absorbed  obviates  the  necessity 
of  disturbing  the  dressing  in  order  to  remove  it.  It  is  employed  in 
operations  upon  bones  and  soft  parts,  following  which  immobilization 
is  desirable.  The  arrangement  of  catgut  for  the  purpose  is  shown  in 
Fig.  51.  A  number  of  strands  of  fine  catgut  meet  the  indication  more 
satisfactorily  than  do  a  few  heavy  ones,  for  the  reason  that  the  former 
possess  the  greater  capillarity. 

Rubher  tissue  for  drainage  is  also  used  in  the  same  class  of  cases  as 
is  silk  worm  gut  and  tube  drainage.     It  should  be  used  to  drain  cav- 


FiG.  52. —  KuBBEB  Tissue  Kolled  on  Itself  for  Drainage  Purposes. 

ities  of  moderate  dimensions.  The  tissue  is  cut  to  the  desired  size 
and  rolled  upon  itself  in  a  tubular  form  (Fig.  52). 

The  cigarette  drain  is  the  outcome  of  an  effort  to  overcome  the 
objectionable  features  of  gauze  drainage  and  tube  drainage.  It  does 
not  adhere  to  the  sides  of  the  wound  as  do  the  textile  fabrics,  and  it 
also  possesses  capillarity,  draining  uphill,  which  tube  drainage  will 
not  do.  It  consists  of  gauze  rolled  to  the  desired  thickness,  its  diam- 
eter depending  upon  the  size  of  wound  area  to  be  drained,  and  is 
surrounded  with  rubber  tissue  leaving  a  portion  of  gauze  at  either 
end  uncovered  (Fig.  53).  The  cigarette  drain  is  the  one  most  gener- 
ally used  in  surgery.  It  is  clean,  easily  handled,  and  effective.  It 
may  be  used  in  aseptic  or  infected  wounds.  In  the  latter  instance, 
however,  it  must  be  changed  frequently,  as  the  gauze  very  soon 
becomes  a  culture  medium  for  bacteria.  The  fact  that  its  replacement 
is  attended  by  little  disturbance  makes  this  only  slightly  objectionable. 

Ruhher  tissue  drains  do  not  act  by  capillarity,  and  should  be 
employed  only  at  dependent  portions  of  wounds.     Rubbc^'  tube  drain- 


THE  TREATMENT  OF  WOUNDS  77 

age,  except  in  instances  such,  as  empyema  or  suppurative  osteomyelitis, 
need  not  be  maintained  for  more  than  three  or  four  days.  It  may 
then  be  replaced  by  rubber  tissue  drainage,  and  ultimately  by  a  silk- 
worm gut  drain,  and  this  removed  strand  by  strand  as  indicated  by 
the  amount  and  character  of  the  discharge  from  the  wound.  Pro- 
longed maintenance  of  drainage  is  prejudicial  to  repair,  and  in  no 
instance  should  drainage  agents  be  permitted  to  make  undue  pressure 
on  the  tissues. 

Foreign  bodies  accessible  through  the  wound  of  entrance  are  to  be 
removed  with  forceps  or  other  mechanical  appliances  under  careful 
avoidance  of  trauma. 

Deeply  located  foreign  bodies,  such  as  needles,  glass  splinters,  par- 
ticles of  wood,  portions  of  cutting  instruments,  projectiles,  and  the 
shreds  of  clothing  usually  propelled  into  the  tissue  in  gunshot  wounds, 
demand  careful  consideration  in  deciding  the  method  of  treatment. 

All  foreign  bodies  that  penetrate  the  deeper  tissues  are  accompanied 


Fig.  53. —  Cigarette  Drain. 

by  bacteria  which  are  either  attached  to  the  penetrating  material,  or 
carried  inward  from  the  clothing  or  skin.  Foreign  bodies  with  smooth 
surfaces  are  less  extensively  infested  vt^ith  bacteria  than  are  those 
whose  surfaces  are  uneven.  Experimental  study  shows  that  even 
smooth  projectiles  carry  bacteria  into  the  deeper  zones  of  the  body, 
and  that  the  friction  resulting  from  penetration  does  not  remove  the 
microorganisms,  though  highly  virulent  pathological  processes  are 
rarely  caused  by  trauma  of  this  sort.  V.  Bergman's  extensive  studies 
during  the  Turco-Russian  w^ar  of  1877-1878,  resulted  in  the  conclu- 
sion, that,  although  projectiles  that  penetrated  the  body  deeply  were 
fertilized,  secondary  infection  did  not  occur  and  prompt  healing  took 
place,  provided  the  wound  of  entrance  w^as  immediately  sealed  with  a 
dry  antiseptic  dressing  and  meddlesome  probing  or  irrigation  avoided; 
and  that  the  slight  primary  infection  of  the  w^ound  canal  does  not  eX' 


78  WOUNDS 

tend  beyond  the  external  parts,  which  would  seem  to  show  that  the  nat- 
ural antibacterial  powers  sufficed  to  accomplish  this  fortunate  outcome. 

On  the  other  hand,  the  penetrating  of  a  foreign  body  may  result  in 
a  menacing  primary  infection,  such  as  tetanus,  putrefactive  or  pyo- 
genic processes,  though  this  occurs  only  in  instances  in  which  the 
injury  is  caused  by  foreign  bodies  with  rough  surfaces.  Foreign 
bodies  of  this  sort,  together  with  their  accompanying  bacteria,  may 
remain  inactive  for  years,  quietly  resting  in  an  environment  of  con- 
nective tissue,  and  suddenly  —  as  the  outcome  of  injury  that  trauma- 
tizeg  the  embedding  scar  tissue  —  develop  an  acute  suppurative  pro- 
cess, the  local  and  constitutional  manifestations  of  which  are  as  severe 
in  character  as  would  have  obtained  had  a  primary  infection  occurred. 

Clinical  experience  leads  to  the  conclusion  that  foreign  bodies  in 
wounds  should  be  removed : 

1.  Wlien  visible  through  the  port  of  entrance. 

2.  When  thej^  are  of  a  nature  that  frequently  leads  to  tetanus  or 
infection  (wood  splinters). 

3.  Those  palpable  immediately'  under  the  skin. 

4.  Those  that,  immediately  after  penetration,  or  later,  as  the 
result  of  muscular  action,'lie  in  contact  with  tissues  susceptible  to 
mechanical  irritation,  such  as  nerve  trunks,  mucous  membranes,  or 
synovia  of  the  joints;  also  in  instances  where  sharp  pointed  foreign 
bodies  (needles,  glass,  etc.)  give  rise  to  pain. 

5.  When  the  wound  canal  is  the  seat  of  phlegmonous  inflammation 
or  tetanus  infection. 

No  attempt  should  be  made  to  locate  foreign  bodies  by  means  of 
forceps,  etc.  Kemoval  should  be  effected  through  an  incision  located 
as  far  as  possible  from  the  original  wound,  on  the  ground  that  the 
latter  is  already  infected.  Metallic  foreign  bodies  are  of  course  read- 
ily located  by  means  of  stereoscopic  Rontgenology,  in  other  instances, 
pain,  tenderness,  disturbance  of  function,  and  the  history  of  the  case 
must  be  taken  into  account  in  locating  the  offendipg  material. 

Healing  of  the  wound  with  the  foreign  body  in  situ  should  be  per- 
mitted when  the  foreign  body  is  smooth,  deeply  located,  and  does  not 
giA'e  rise  to  symptoms.  If  disturbances  occur  after  healing,  the  mag- 
nitude of  the  procedure  necessary  to  effect  removal  must  be  carefully 
considered  before  the  attempt  is  made  (bullet  in  brain  or  spinal  cord). 

The  general  rules  governing  the  care  and  treatment  of  accidentally 
inflicted  wounds  may  be  briefly  summarized  as  follows : 

First  aid  dressing  should  consist  of  covering  the  wound  with  dry 
sterile  gauze. 


THE  TREATMENT  OF  AVOUNDS  79 

,  Subsequent  care  of  the  wound  consists  in  covering  it  while  cleansing 
the  contiguous  parts.  In  the  presence  of  severe  bleeding,  temporary 
hemostasis  is  effected  with  the  v.  Esmarch  girdle.  Cleansing  of  the 
wound  area  in  the  same  manner  as  the  preparation  of  the  operative 
field  preliminary  to  surgical  invasion.  Draping  of  the  surroundings 
with  sterile  towels.  Narcosis  when  necessary  and  when  possible. 
Careful,  gentle  separation  of  the  edges  of  the  wound  with  retractors 
(not  fingers)  and  visual  scrutiny  wdth  the  view  of  discovering  injured 
tendons,  nerves,  etc.  Removal  of  dirt  and  foreign  bodies  with  forceps, 
and  blood  clots  with  gauze  sponges ;  when  much  dirt  is  present,  3  per 
cent  Ho  O2  may  be  permitted  to  trickle  gently  into  the  wound.  Appli- 
cation of  forcipressure  and  deligation  of  blood  vessels.  Excision  of 
lacerated  shreds  of  tissues.  Emplojinent  of  tamponade,  drainage, 
or  suture.  Application  of  dry,  aseptic  protective  dressing,  and 
immobilization  of  injured  part. 


BIBLIOGRAPHY 

1.  V.  Esmarch.     Cbir.  kons:.  Vehr.  1896,  ii. 

2.  J.  D.  Bryant.     Op.  Surg,  i,  Appleton,  N.  Y.,  1905. 

3.  Wyeth.     Same  as  No.  2. 

4.  MOMBURG.     Zentrbl.  f.  Chir.  1908. 

5.  Sahli.     Zeitscbr.  f.  klin.  Med.  Bd.  56,  1905. 

6.  LossEX.     Deutsch.  Zeitscbr.  f.  Chir.  Bd.  76,  1905. 

7.  Dastre  and  Floresco.  .  Quoted  by  Landmann,  Mit.  a.  d.    Grenzeeb.  Bd. 

14,  1905. 

8.  V,  Bergmann.     Die  Scbicksale  der  Transfusion,  Berlin,  1883. 

9.  MoRAwiTZ.     Mlincb.  med.  Wocb.,  1907. 

10.  Crile.     Hemon-bage  and  Transfusion,  N.  Y.,  1909. 

11.  Burger.    Zentrbl.  f.  Cbir.  1908. 

12.  Berxheim.     Anns.  Surg-.  October,  1909. 

13.  GuiLLOT.     Arcb.  med.  Cbir.  Nonnandie,  1913. 

14.  Carrel.     See  Crile  No.  10. 

15.  Pope.    Jr.  A  M.  A.,  Ix,  1913. 

16.  Beexizer.     South.  Med.  Jr.,  1919,  xii. 

17.  "  Sexcert.    Med.  &  Surg.  Tberap.  iii,  1918,  Appleton. 

18.  Ki-TTXER.     Chir.  kons.  Vebr.  i,  1903. 

19.  KuHX.     Deutscb.  Zeitscbr.  f.  Cbir.  Bd.  122,  1913. 

20.  HoxsELL.     Beitr.  z.  klin.  Cbir.  Bd.  27,  1900. 

21.  Lexer.    Allg.  Cbir.  (7tb  ed.)  i,  1904,  Stuttirai-t. 


CHAPTER  IV 

GBNEEAL   CONSIDEEATIONS   EEGAEDING   ASEPTIC    TECHNIC 

"When  Pasteur  (1861)  showed  that  fermentation  and  putrefaction 
of  organic  substances  were  caused  by  fertilization  with  ferments  of 
vegetable  or  animal  origin,  he  laid  the  foundation  upon  which  was 
built  Lister's  idea,  that  wound  infections  must  have  a  similar  cause, 
and  thus  was  created  the  monument  marking  the  era  most  fruitful  of 
results  in  the  entire  history  of  surgery. 

Lister  and  his  school  (1867)  quite  properly  believed  that  the 
destruction  of  the  living  organisms,  as  they  exist  in  all  agents  — 
including  the  air  • —  coming  in  contact  with  wound  surfaces  would  obvi- 
ate the  occurrence  of  infection.  Lister  found  that,  by  sprinkling 
carbolic  acid  upon  irrigated  pasture  land,  the  disagreeable  odor  of 
the  sewage  was  abolished,  and  that  the  cattle  feeding  upon  these  fields 
were  exempt  from  worms.  Carbolic  acid  was  used  before  this  time 
by  an  Italian  surgeon  (Bottini,  1863)  for  the  purpose  of  cleansing 
surgical  w'ounds,  although  Lister  was  not  aware  of  Bottini 's  work,  nor 
was  that  of  the  latter  based  upon  the  epoch  making  conception  of 
Lister.  Immediately  following  Lister's  announcement,  and,  indeed, 
for  a  considerable  period  of  time  thereafter,  the  skin,  hands,  instru- 
ments, sponges,  suture  and  ligature  material  were  carefully  disin- 
fected with  a  5  per  cent  solution  of  carbolic  acid,  and  the  air,  which 
was  believed  to  be  particularly  dangerous  in  this  connection,  was 
impregnated  with  a  2.5  per  cent  solution  of  the  same  agent,  by  means 
of  a  vaporizer.  Indeed,  accidentally  inflicted  and  operative  wounds 
were  covered  wnth  a  dressing  saturated  with  carbolic  acid  solution. 

The  destruction  of  infection  producing  substances  by  means  of  chem- 
ical agents  was  given  the  term  "antisepsis,"  and  properly  may  be 
regarded  as  a  prophylactic  measure.  The  objectionable  features 
attendant  upon  the  use  of  chemical  agents  soon  led  (1886)  to  the 
development  of  the  technic  of  asepsis,  which  owes  its  progressive 
refinement  to  the  work  of  the  bacteriologist.  During  the  transitional 
period  wide  deviations  from  the  straight  path  were  made,  resulting  in 

80 


CONSIDERATIONS  REGARDING  ASEPTIC  TECHNIC       81 

unnecessarily  rigid  teclinical  indulgences,  from  which,  indeed,  even 
the  present  day  technic  is  not  exempt. 

When  it  was  shown  that  bacteria  capable  of  causing  wound  infec- 
tion were  universally  distributed,  and  that  their  recognition  was 
dependent  upon  their  isolation  and  culture  in  receptive  media  (Koch, 
1876)  ;  and,  beyond  this,  it  was  realized  that  traumatized  tissues 
presented  a  peculiar  accord  in  this  connection,  the  conception  of 
Lister  became  widely'  accepted,  and  the  efforts  of  all  the  surgeons  in 
the  world  were  expended  in  the  exercise  of  antiseptic  technie  and  its 
improvement.  It  was  soon  recognized  that  the  carbolic  acid  vaporizer 
had  a  tendency  to  propel  bacteria  into  the  wound,  and  that  wound 
infection  did  not  have  its  origin  in  the  air,  but  was  rather  the  outcome 
of  contamination  from  the  surgeon's  hands,  instruments,  etc.,  and 
although  the  vaporizer  was  banished,  the  irrigator  continued  to  pour 
carbolic  acid  —  and  later  corrosive  sublimate  solution,  into  the 
operative  field. 

It  was  next  shown  that  chemical  antiseptics  combined  with  the 
albumin  of  the  body,  and  did  not  come  in  contact  with  bacteria  in 
Bufficient  quantity  to  be  thoroughly  effective.  Shlange  showed  that 
the  antiseptics,  with  which  dressings  were  saturated,  evaporated,  and 
that  bacteria  again  made  their  appearance;  it  also  was  shown  that 
lavage  of  wounds  with  antiseptic  solutions  caused  excessive  exfoliation 
of  cellular  elements  (necrosis  of  granulation  tissue),  which  delayed 
healing  and  mechanically  distributed  bacteria  into  tissues  contiguous 
to  those  already  infected. 

These  findings,  based  upon  bacteriological  study,  led  to  sterilization 
with  steam,  and  by  boiling,  which,  together  with  mechanical  cleansing, 
are  the  most  important  measures  of  the  present  day  asepsis. 

Antiseptics  are  still  necessary  to  surgical  technic,  though  their  office 
is  of  minor  importance.  It  would  seem  best  to  have  the  terms, 
physical  and  chemical  antisepsis,  used,  and  the  word  asepsis  entirely 
eliminated  from  the  terminology  of  surgery. 

The  details  of  asepsis  are  executed  in  various  ways  by  different 
surgeons,  who  perform  their  labors  under  varying  conditions  and,  in 
some  instances,  it  would  seem  as  though  unnecessarily  complicated 
methods  of  procedure  had  been  indulged  in.  The  presentation  of  a 
technic  applicable  to  institutional  work,  and,  in  a  modified  form, 
useful  in  private  practice,  seems  to  meet  the  situation,  rather  than  to 
confuse  the  mind  of  the  student  and  the  practitioner  with  lengthy 
descriptions,  impractical  of  execution. 


CHAPTER  V 

TJiICHNIC   OF  CLEANSING  THE  SUEFACES   OF   THE  BODY 

The  skin  harbors  an  immense  number  of  microorganisms,  among 
which  those  causing  purulent  or  putrefactive  infection  exist  in  the 
greatest  quant  it}'.  These  bacteria  infest  the  thin  layer  of  sebaceous 
secretion,  the  superficial  epidermal  layer,  the  mouths  of  hair  follicles, 
and  the  excretory  ducts  of  the  sudoriferous  glands  of  the  skin,  where 
they  nest  in  its  irregularities  and  crevices,  all  of  which  render  their 
complete  destruction  or  removal  exceedingly  difficult,  and,  indeed, 
from  the  viewpoint  of  exact  bacteriology,  impossible  (Hagler^). 

THE  CLEANSING  OF  THE  HANDS 

In  hospitals,  and,  at  times,  in  private  practice,  the  mechanical 
cleansing,  i.  e.,  the  scrubbing  of  the  hands  and  forearms,  is  performed 
in  a  chamber  contiguous  to  the  operating  room.  In  principle,  it  is 
best  to  perform  this  act  in  the  operating  room  itself,  with  the  view 
of  obviating,  en  route  to  the  operating  chamber,  contact  with  fertilized 
areas. 

For  convenience  a  table  is  placed  beside  the  wash  basin,  and  on  this 
a  glass  jar  containing  sterile  brushes,  orange  sticks,  and  a  nail  file, 
submerged  in  a  1  per  cent  solution  of  carbolic  acid ;  a  jar  of  green 
soap,  and  two  enameled  dishes,  one  containing  chlorid  of  lime  and  the 
other  sodium  carbonate.  In  hospital  practice,  a  canister  divided  into 
compartments,  each  containing  a  brush,  may  be  used  instead  of  the 
glass  jar.  A  large  quantity  of  water  and  a  liberal  amount  of  soap 
should  be  made  available.  As  mechanical  cleansing  does  not  destroy 
the  bacteria,  they  must  be  removed  together  with  a  portion  of  the 
epidermis ;  consequently  the  hands  should  be  immersed  in  warm  water 
for  a  few  minutes  before  the  soap  is  applied  with  the  view  of  macerat- 
ing the  epidermis,  to  facilitate  its  removal.  This  manipulation  should 
take  place  in  a  roomy  wash  basin,  the  supply  cocks  of  which  are 
operated  by  the  foot,  though  in  private  practice  the  supply  cocks  may 
be  manipulated  by  an  attendant.  After  the  hands  and  forearms  have 
been  soaked  for  several  minutes,  they  are  rinsed  in  the  water,  and  the 

82 


CLEANSING  THE  SURFACES  OF  THE  BODY     83 

supply  ill  the  basin  is  drained  off  and  replaced  with  fresh  water. 
The  hands  and  forearms  are  coated  with  green  soap,  which  is  thor- 
oughly rubbed  into  the  skin  by  means  of  a  piece  of  gauze.  For  this 
purpose  green  soap  that  has  been  sterilized  by  heat  is  the  most  useful 
agent,  as  it  contains  considerable  free  caustic  potash  (Reichenbach-), 
which,  together  with  the  fatty  sebum  and  exfoliated  epidermis,  makes 
a  mixture  favorable  to  removal.  Haste  should  be  avoided  at  this  time 
to  permit  a  thorough  incorporation  of  the  soap  with  the  skin. 
"While  the  soap  is  in  contact  with  the  skin,  the  finger  nails  are  cleansed 
with  a  sharpened  orange  wood  stick  or  nail  file,  preferably  the  former, 
which  is  less  liable  to  abrade  the  contiguous  skin. 

The  finger  nails  should  not  be  closely  trimmed  immediately  before 
the  preparation  of  the  hands,  as  the  exposed  underlying  skin  folds  are 
difficult  to  cleanse. 

The  tincture  of  green  soap  and  the  ordinary  toilet  soaps  may  be 
used,  although  they  are  not  as  effective  as  the  agent  advised  above. 

The  mixture  of  soap,  saponified  sebum,  macerated  epidermis,  and 
bacteria,  is  now  displaced  with  running  water,  the  water  in  the  wash 
basin  again  replaced,  and,  with  fresh  green  soap,  the  hands  and  fore- 
arms are  freely  lathered  with  the  aid  of  the  brush  taken  from  the 
glass  jar  or  canister.  The  brush  should  be  used  gentlj^  and  should 
not  be  sufficiently  harsh  to  scratch  the  skin,  which  is  now  particularly 
susceptible  to  injury.  This  lather  is  now  washed  away  with  clean 
running  water. 

This  constitutes  the  mechanical  cleansing  of  the  hands  and  forearms, 
which  requires  from  seven  to  ten  minutes  and  is  the  most  important 
step  in  their  preparation.  The  immersion  of  the  hands  in  chemical 
agents  does  not  achieve  sterility 'Of  the  skin.  If  any  measures  in  this 
connection  need  be  neglected,  it  would  most  conserve  the  interest  of 
the  patient  to  disregard  certain  manipulations  destined  to  destroy 
bacteria  by  chemical  action  than  to  err  in  the  mechanical  cleansing. 
The  practitioner  is  admonished  not  to  disregard  this  warning,  since 
bacteriological  study  shows  that  bacterial  flora  are  considerably  less 
upon  the  skin  mechanically  cleansed  in  the  manner  described  than 
when  reliance  is  placed  upon  the  bactericidal  effect  of  chemical  agents 
used  to  the  exclusion  of  mechanical  cleansing. 

After  the  hands  and  forearms  have  been  treated  as  described,  they 
are  coated  with  chlorid  of  lime  made  into  a  paste  with  water,  and  this 
is  followed  by  applying,  while  the  lime  is  still  on  the  skin,  sodiuni 
carbonate,  thus  liberating  chlorin,  an  active  bactericidal  agent. 


84  WOUNDS 

Care  should  be  taken  not  to  scratcli  the  skin  with  crystals  of  either 
lime  or  soda.  The  application  gives  rise  to  a  sensation  of  warmth 
that  soon  disappears.  After  the  feeling  of  warmth  leaves,  the  mix- 
ture is  removed  with  a  0.1  per  cent  solution  of  corrosive  sublimate, 
a  piece  of  sterile  gauze  being  used  for  the  purpose.  The  application  of 
the  mixture  at  frequent  intervals  causes  the  development  of  dermatitis. 
When  several  operations  are  performed  at  one  sitting,  the  irritating 
effect  of  the  chlorin  may  be  obviated  by  applying  lime  and  soda 
preceding  the  first  operation  and  omitting  their  use  before  the 
succeeding  ones. 

Complete  removal  of  the  mixture  is  accomplished  by  rinsing  the 
hands  and  forearms  in  a  solution  of  sodium  carbonate  (2  per  cent), 
before  the  corrosive  sublimate  solution  is  applied.  The  hands  and 
forearms  are  now  immersed  in  alcohol,  which  is  rinsed  off  with  sterile 
water. 

It  is  not  claimed  that  the  skin  of  the  hands  and  forearms  is  free 
from  the  bacterial  flora  after  the  employment  of  the  methods  of 
cleansing  described.  Bacteriological  examination  of  the  finger  nails 
and  forearms  after  cleansing  show  that  bacteria  still  thrive  in  these 
situations.  It  is  a  singular  fact  that  the  nearest  approach  to  sterility 
in  this  connection  is  obtained  after  the  operator  has  performed  one  or 
more  operations,  the  bacterial  flora  being  less  marked  in  proportion 
to  the  length  of  time  the  hands  have  been  in  contact  with  aseptic  or 
antiseptic  material.  This  would  argue  that  the  perspiration  mechan- 
ically cleanses  the  skin,  and  that  the  growth  of  bacteria  is  exhausted 
as  the  outcome  of  copious  dilution  of  its  culture  medium  by  substances 
not  fertilized.  At  best,  an  inhibition  of  the  growth  of  bacteria  —  the 
result  of  the  combination  of  the  mechanical  cleansing  and  antiseptic 
lavage  —  is  achieved ;  yet  this  would  seem  to  be  sufficient  for  all 
practical  purposes. 

Modification  of  the  method  described  is  employed,  and,  indeed,  cer- 
tain variations  are  perfectly  permissible ;  however,  as  far  as  the 
mechanical  cleansing  is  concerned,  no  method  yet  presented  is  more 
useful. 

The  lime  and  soda  mixture  may  be  replaced  by  coating  the  hands 
with  a  saturated  solution  of  permanganate  of  potash,  which  is  later 
displaced  with  oxalic  acid;  or  various  antiseptic  solutions  may  be 
used  in  place  of  either  of  those  mentioned,  but  the  rest  of  the  manipu- 
lations are  not  susceptible  of  modification. 

The  general  care  of  the  skin  of  the  hands  and  of  the  finger  nails  is 


CLEANSING  THE  SURFACES  OF  THE  BODY  85 

an  important  consideration.  Indulgence  in  manipulations  that 
endanger  the  integrity  of  the  skin  should  be  avoided,  as  trauma,  fol- 
lowed by  moderate  infection,  makes  cleansing  before  an  operation 
quite  impossible.  Subjecting  the  finger  nails  and  adjacent  skin  to  the 
manipulations  of  professional  "manicurists"  at  frequent  intervals  is 
desirable. 

The  question  of  incasing  the  hands  in  ruhher  gloves  during  contact 
with  the  operative  field  cannot  be  dismissed  with  the  bald  statement 
that,  in  every  instance,  the  patient's  interests  are  best  conserved  by 
the  employment  of  this  measure  of  protection  on  the  part  of  the 
operator  and  his  assistants. 

If  the  hands  could  be  covered  with  an  impermeable  glove,  which 
under  no  circumstances  exposed  the  operative  field  to  contact  with  the 
operator's  skin,  the  problem  would  be  solved,  except  as  to  modification 
of  tactile  sense.  Experience  and  training  may  develop  sufficient  tac- 
tile acuteness  so  that,  in  the  vast  majority  of  instances,  the  presence 
of  the  glove  will  not  constitute  a  determining  hindrance  in  the  execu- 
tion of  surgical  technic ;  yet  there  are  instances  in  which  it  is  advan- 
tageous to  execute  the  necessary  manipulations  without  this  handicap. 

If  it  be  true,  that  the  development  of  infection  is,  to  a  considerable 
degree,  determined  by  the  amount  of  bacterial  flora  introduced,  it 
would  seem  rational  that  the  assistants  should  wear  gloves  in  all 
instances  and  the  operator  in  most  cases,  the  latter  abstaining  from 
their  employment  when  the  manipulations  become  inaccurate  and 
prolonged  as  a  result  of  their  use. 

As  already  stated,  infective  bacteria  normally  inhabit  the  ducts  of 
the  sudoriferous  and  sebaceous  glands  of  tTie  skin,  and  their  complete 
destruction  is  impossible  b}'  anj^  known  method.  "When  the  freshly 
cleansed  hands  are  incased  in  rubber  gloves,  the  glands  are  stimulated 
into  hypersecretion,  and  a  thin  mixture  of  bacteria  incorporated  sweat 
and  fluid  sebum  lies  in  a  layer  between  the  skin  and  glove. 

If,  during  the  operation,  contact  with  sharp  instruments,  bone 
spicula,  etc.,  causes  solution  of  continuity  of  the  glove,  this  mixture 
is  forcibly  projected  into  the  wound.  This  objectionable  occurrence 
may,  perhaps,  be  best  obviated  hy  wearing  cotton  gloves  for  the  first 
portion  of  the  operation,  as  they  absorb  the  infective  mixture  and  can 
be  changed  frequently,  that  is,  a  clean  pair  can  be  substituted  before 
the  mixture  permeates  to  their  outer  surface. 

It  would  seem  to  be  rational  to  wear  cotton  gloves  while  executing 
the  technic  of  the  first  portion  of  the  operation,  that  is,  while  making 


86 


WOUNDS 


approach  to  the  area  where  more  delicate  manipulations  are  necessary, 
and  then  substitute  rubber  gloves,  or,  if  necessary,  the  operator  may 
rinse  his  hands  in  a  solution  of  corrosive  sublimate  0.1  per  cent,  which 
is  displaced  with  sterile  water,  and  proceed  with  the  operation  with 
bare  hands. 

Cotton  gloves  are  less  liable  to  be  injured  during  the  manipulations 
involved  in  tying  ligatures  and  inserting  sutures  than  are  rubber 
gloves.  The  rubber  gloves  should  be  provided  with  gauntlets  that 
cover  the  wrists.     The  forearm  may  be  incased  in  a  sterile  gauze 


Fig.  54. —  Forearm  Covered  by  Long  Sleeve  of  Gown,  Gauntlet  op  Rubber 
Glove  Turned  over  Sleeve  and  Held  in  Place  by  Gauze  Band. 

bandage,  though  the  method  most  effective  for  the  purpose  is  to  cover 
the  entire  arm  with  the  long  sleeve  (Fig.  54).  As  the  ends  of  the 
fingers  are  most  likely  to  harbor  bacteria,  they  maj^  be  covered  with 
finger  cots.  However,  this  is  not  recommended  for  use  in  prolonged 
operations,  although  exceedingly  convenient  when  the  operation 
consists  of  the  simple  opening  of  an  abscess  or  the  like. 


THE  CLEANSING  OF  THE  SKIN  OF  THE  OPERATIVE  AREA 

The  cleansing  of  the  skin  of  the  operative  area  should  be  preceded 
by  a  warm  general  bath.  The  mechanical  cleansing  of  the  skin  is 
initiated  by  shaving,  irrespective  of  the  area  to  be  attacked,  with  the 


CLEANSING  THE  SURFACES  OF  THE  BODY     87 

view  of  removing  loose  epidermis  and  invisible  hairs.  Visible  accumu- 
lations of  dirt  are  removed  by  friction  with  ether,  alcohol  or  benzin. 
In  all  other  respects  the  cleansing  of  the  skin  of  the  operative  area  is 
similar  to  the  cleansing  of  the  hands. 

In  cases  requiring  emergency  operations,  or  when  infected  areas 
are  attacked  and  in  cases  requiring  minor  operative  effort,  the  iodin 
disinfection  of  Grossich^  may  be  employed.  The  Grossich  method 
consists  of  applying  to  the  dry  skin  a  5  per  cent  tincture  of  iodin, 
preceded  by  dry  shaving.  The  skin  must  be  free  from  water  or 
alcohol  when  the  iodin  is  applied. 

The  application  of  iodin  is,  at  times,  followed  by  dermatitis,  due  to 
its  decomposition  into  iodohydrates  (JungengeP),  a  condition  which 
may  lead  to  disturbances  in  the  wound  of  sufficient  severity  to  make 
the  general  employment  of  the  Grossich  method  inadvisable.  Bac- 
teriological analyses  indicate  that  disinfection  by  the  Grossich  method 
is  not  as  effective  as  is  cleansing  of  the  skin  by  the  mechanical  and 
chemical  means  already  described. 

THE  CLEANSING  OF  MUCOUS  MEMBRANES 

It  is  impossible  to  sterilize  mucous  membranes.  The  application  of 
antiseptics  does  not  destroy  the  bacteria  contained  in  the  secretions  of 
these  membranes,  but  does  produce  irritation  which  favors  the  develop- 
ment of  infection.  In  addition,  chemical  antiseptics  are  likely  to  be 
absorbed  and  give  rise  to  constitutional  poisoning,  as  has  been  observed 
in  connection  with  corrosive  sublimate  used  in  vaginal  douches. 

A  considerable  reduction  of  bacterial  flora  may  be  attained  by  fre- 
quent, copious  lavage  of  the  buccal  cavity,  with  1 :5000  potassium  per- 
manganate solution ;  and  of  the  bladder  and  rectum,  with  sterile  saline 
solution  or  sterile  2  per  cent  boric  acid  solution. 

During  operations  involving  opening  of  the  lumen  of  the  gastro- 
intestinal canal,  the  mucous  membrane  is  cleansed  by  the  frequent 
application  of  sterile  gauze  wipes,  supplemented  by  the  local  applica- 
tion of  tincture  of  iodin. 


BIBLIOGRAPHY 

1.  Hagler.     Handereinigiing",  Basel,  1900. 

2.  Reichexbach.     Zeitschr.  f.  Hyg.  u.  Infkrankh.  Bd.  59,  1908. 

3.  Grossich.     Zentrbl.  f.  Chir.  1908. 

4.  JuNGEXGEL.     Miinch.  med.  Woeh.,  1910. 


CHAPTER  VI 

STEEILIZATION    OF    INSTRUMENTS 

The  immersion  of  instruments  in  boiling  water  for  ten  minutes 
renders  them  absolutely  sterile.  The  employment  of  antiseptic  solu- 
tions, irrespective  of  the  chemical  agent  used,  does  not  accomplish  the 
purpose.  A  lengthy  discussion  in  this  connection  is  unnecessary. 
Before  boiling,  instruments  should  be  cleansed  with  a  brush  under 
running  water. 

The  most  resisting  infectious  bacterium  —  the  anthrax  bacillus  — 
is  killed  in  two  minutes  by  exposure  to  boiling  water,  thus,  the  margin 


Fig.  55. —  Instrument  Sterilizer. 


of  safety,  i.  e.,  ten  minutes  of  boiling  heat,  meets  every  indication. 

The  rusting  of  instruments  may  be  prevented  by  adding  sodium 
carbonate  to  the  water  (1  per  cent).  The  impurities  in  ordinary  tap 
water  (lime,  etc.)  are  probably  responsible  for  the  formation  of  rust; 
therefore,  distilled  water  should  be  used. 

The  instruments  should  be  removed  from  the  solution  while  it  is  still 
boiling,  as  the  heat  remaining  in  the  instruments  drives  off  all  but  the 


STERILIZATION  OF  INSTRUMENTS 


89 


smallest  quantity  of  moisture,  and  this,  in  turn,  is  taken  up  by  the 
residual  sodium  carbonate.  Chemically  pure  soda  should  be  used ;  all 
of  which  would  seem  to  show  that  attention  to  detail  in  this  connection 
will  obviate  unnecessary  deterioration  of  apparatus. 

After  the  operation  the  cleansing  is  repeated,  the  instruments  are 
again  boiled,  with  green  soap  added  to  the  solution  and  then  carefully 
dried. 

The  apparatus  most  commonly  used  for  boiling  instruments  is  shown 
in  Fig,  55.  It  is  made  of  heaxy  copper,  tinned  inside  and  nickel 
plated  outside,  and  is  fitted  with  a  perforated  bottom  tray  which 
permits  the  ready  removal  of  the  instruments.  This  particular 
boiler  is  furnished  with  a  gas  Bunsen  burner,  but  the  same  apparatus 
is  obtainable  with  alcohol,  petroleum,  or  electric  heating  attachments. 


Fig.  56. —  Portable  Instrument  Sterilizer  with  Detachable  Legs. 


Practically  the  same  apparatus  is  shown  in  Fig.  56,  except  that  there 
is  no  burner  attachment,  and  it  may  be  employed  either  with  an 
alcohol  flame  or  set  directly  upon  a  stove.  For  the  latter  purpose, 
the  legs  are  detachable.  This  apparatus  is  useful  for  conveying  to 
the  seat  of  operation  instruments  which  may  then  be  sterilized  by 
boiling,  in  accordance  with  the  source  of  heat  available.  This  illustra- 
tion shows  the  perforated  tray. 

Cutting  instruments,  especially  knives,  when  boiled  rapidly,  deteri- 
orate despite  all  precautions.  Knives  may  be  submerged  in  pure 
carbolic  acid  for  twenty  minutes,  and  later  immersed  in  95  per  cent 


90 


WOUNDS 


alcohol  for  an  additional  twenty  minutes  —  a  procedure  whicli  does  not 
seem  to  impair  the  cutting  edge,  but  does  accomplish  sterility. 

Grosse^  has  devised  a  method  of  heat  sterilization  which  does  not 
cause  rust  to  form.    The  knives  are  placed  in  a  metal  rack  (Fig.  57) 


Fig.  57. —  Glass  Tube  with  Knives  for  Steam  Sterilization. 

that  is  slipped  into  a  glass  tube,  provided  with  a  stopper.  The  entire 
tube,  after  being  closed,  is  placed  in  a  steam  pressure  sterilizer 
(p.  93)  and  treated  as  described  under  the  head  of  dressing 
sterilization. 


BIBLIOGRAPHY 

1.     GuossE.     Bryant's  Op.  Sury.  i,  N.  Y.,  1905. 


CHAPTER  VII 
STERILIZATION  OF  DRESSINGS,  WIPES,  GOWNS,   ETC. 

General  Considerations. —  In  properl}'  equipped  hospitals,  all  material 
coming  in  contact  with  the  patient  during  the  execution  of  surgical 
technic  is  sterilized  by  heat.  Heat  is  undoubtedly  the  most  effective 
agent  in  this  connection,  yet  in  the  varj^ing  conditions  under  which 
operations  have  to  be  undertaken,  its  employment  is  not  at  all  times 
feasible.  Chemical  sterilization  is,  in  some  instances,  a  necessity,  and 
if  patiently  and  carefully  executed,  accomplishes  the  intent. 

A  judicious  combination  of  heat  and  chemical  sterilization,  together 
with  mechanical  cleansing,  is  almost  always  obtainable,  i.  e.,  towels  and 
even  gowns  may  be  boiled,  and  put  on  wet  in  case  of  necessity;  but, 
if  available,  steam  heat  should  be  employed  for  the  sterilization  of 
textile  fabric,  as  it  renders  it  more  readily  handled. 

Various  physical  agents,  such  as  cold,  light,  and  dryness,  possess 
bactericidal  power,  though  none  of  these  is  as  effective  nor  as  readily 
controlled  as  heat.  Sunlight  and  certain  forms  of  concentrated  artifi- 
cial light  are  capable  of  destroying  bacteria,  but  the  process  necessary 
to  accomplish  the  desired  end  is  a  prolonged  and  complicated  one,  and 
is  not  of  practical  utility  in  surgery. 

Cold  is  feebly  bactericidal.  Frost,  which  has  been  so  generally 
regarded  as  destructive  to  malarial  and  yellow  fever  poisons,  destroys 
only  the  carriers  of  infection  —  such  as  the  mosquito,  and  leaves 
unharmed  the  infecting  agent. 

Dryness  destroys  the  cholera  germ,  but  of  itself  favors  the  growth 
and  life  of  bacteria  generalh". 

Dry  heat  at  a  temperature  of  302°-329°F.  (150°-165°C.)  will 
destro}'  bacterial  life  in  one  hour. 

Moist  heat  at  a  temperature  of  212°F.  (100°C.)  will  destroy  all 
bacteria  and  spores  in  a  few  minutes. 

The  difference  in  the  bactericidal  effect  of  dr^-  as  compared  with 
moist  heat  should  be  borne  in  mind  when  steam  heat  is  not  available  for 
sterilization,  and  dressings,  etc.,  are  baked  in  an  oven  preliminary 
to  operation. 

91 


92 


WOUNDS 


Steam  and  air  have  a  certain  molecular  antagonism  in  a  given  area 
until  there  is  an  equalization  of  the  difference  of  expansion  in  these  two 
bodies;  this  accounts  for  the  peculiar  inequality  of  action  in  apparatus 
which  do  not  allow  of  the 
removal  of  air  from  the 
sterilization  chamber  be- 
fore steam  is  caused  to 
enter. 

The  bactericidal  potency 
of  steam  depends  upon  its 
temperature,  that  is,  an- 
thrax spores  will  be  de- 
stroyed by  steam  at  a  tem- 
perature of  194°F.  (90°C.) 
in  twenty  minutes,  and  at 
a  temperature  of  203°F. 
(95°C.)  in  five  minutes. 

The  thermal  death  point 
of  bacteria  bears  a  certain 
relationship  to  the  coagul- 
ability of  albumin.  Com- 
paratively little  heat  is  re- 
quired to  destroy  bacteria 
in  albumin  in  solution  or 
in  a  moist  state;  on  the 
other  hand  if  the  albumin 
is  dry,  the  bacteria  will 
withstand  a  high  degree  of 
temperature  for  a  long 
time.  When  moist  heat  at 
212°F.  (100°C.)  comes  in 
contact  with  a  spore,  it  is 
killed  as  soon  as  it  ab- 
sorbs enough  moisture  to 
allow  of  coagulation. 

A    sterilizer,    to    accom- 
plish most  readily  the  desired  end,  should  be  constructed  so  as  to 
achieve  the  following : 

Elimination  of  air  from  the  sterilizing  chamber,  the  penetration  of 
the  contents  with  steam,  and  the  prevention  of  condensation  of  water. 


Fro. 


58. —  Steam   Pressure   Steilizer  for 
Dressings,  etc. 


STERILIZATION  OF  DRESSINGS,  WIPES,  GOWNS,  ETC.     93 


Steam  Dressing  Sterilizer. — In  large  institutions  where  steam  power 
plants  are  constantly  in  operation  for  the  purpose  of  furnishing  light, 
heat  and  power,  steam  is  readily  available,  and  is  led  into  the  outer 
jacket  of  the  steam  sterilizer  by  means  of  pipes  which  coil  in  the  outer 

water  jacket  and  heat  the 
water  to  the  desired  tempera- 
ture. In  many  instances  this 
condition  of  atfairs  does  not 
exist,  and  the  water  in  the 
outer  jacket  is  heated  by 
means  of  a  gas  Bunsen 
burner,  placed  beneath  the 
apparatus. 

As  a  matter  of  fact,  it 
makes  no  difference  from 
which  source  the  heat  is  ob- 
tained, provided  it  is  of  suifi- 
cient  quantity  to  develop  the 
temperature  required  for 
sterilization.  The  apparatus 
herewith  described  (Figs.  58- 
59)  encompasses  the  requis- 
ites enumerated  above. 
It  operates  as  follows : 
1.  The  material  to  be  ster- 
ilized is  placed  within  the 
chamber  before  the  burner  is 
lighted  ;  the  door  of  the  cham- 
ber is  securely  locked,  and  the 
air  filtering  cup  valve  F, 
which  is  filled  with  absorbent 
cotton,  is  left  open,  the  handle 
being  in  a  vertical  position,  as 
Fig.  59. —  Sectional  View  of  Steam  Pres-   shown  in  Fio-.  58. 

SURE  Sterilizer  Shown  in  Fig.  58.  •    r»       a  j^.       ?        •'       i  >t 

Z.    Atter  turning  lever  No. 

1  to  the  right,  the  steam  jacket  is  filled  w^ith  clear  water  through  the 
funnel  C.  The  quantit}^  of  water  required  for  sterilization  depends 
upon  the  length  of  time  the  apparatus  is  to  be  operated.  The  jacket 
should  not  be  more  than  half  filled  with  water  (Fig.  59).    The  glass 


94  WOUNDS 

gauge  on  the  side  of  the  apparatus  indicates  the  height  of  the  water 
in  the  jacket. 

3.  Throw  lever  handle  No.  1  back  to  the  left,  and  light  the  burner, 
leaving  the  valve  of  funnel  C  open  until  steam  issues  from  it,  then 
close  tightly.  The  combination  steam  pressure  and  vacuum  gauge  E 
registers  the  conditions  prevailing  in  the  jacket,  and  the  steam  pressure 
safety  valve  D  will  release  steam  as  soon  as  the  latter  exceeds  the 
normal  pressure  of  fifteen  pounds  (one  atmosphere).  Gradually,  as 
the  temperature  of  the  water  jacket  increases,  the  air  in  the  sterilizing 
chamber  becomes  rarefied  and  escapes  through  the  cup  valve  F.  The 
sterilizing  chamber,  therefore,  in  the  first  stage  of  the  process,  serves 
the  purpose  of  a  hot  air  oven,  gradually  warming  the  dressings  pre- 
paratory to  letting  pressure  steam  into  the  chamber. 

4.  As  soon  as  the  combination  steam  and  vacuum  gauge  indicates 
a  steam  pressure  of  fifteen  pounds,  the  safety  valve  will  discharge 
steam  in  excess  of  the  required  pressure.  The  air  filtering  cup  valve 
F.  is  now  closed  by  thrusting  the  handle  into  a  horizontal  position. 

The  already  rarefied  air  in  the  sterilizing  chamber  is  now  exhausted 
by  creating  a  partial  vacuum,  by  opening  valve  No.  2  on  the  steam 
exhaust  pipe,  which  is  accomplished  by  throwing  lever  No.  1  to  the 
right.  The  combination  gauge  E  soon  registers  a  A'acuum  in  the 
chamber. 

When  5  inches  of  vacuum  has  been  established,  clor^e  valve  No.  2, 
whereby  the  pressure  steam  is  made  to  enter  the  sterilizing  chamber. 
The  dressing  material  having  been  prepared,  by  the  air  exhaust 
process,  for  an  eager  absorption  of  live  steam,  will  instantly  be  pene- 
trated by  the  same.  Since  the  inrushing  steam,  which  is  of  a  tempera- 
ture of  250°F.  (121°C.),  comes  in  contact  with  material  that  has  for 
some  time  been  in  contact  with  dry  hot  air  of  nearly  the  same  degree 
of  temperature  as  that  of  the  pressure  steam,  the  latter  will  not  con- 
dense, and,  therefore,  will  not  wet  the  dressings.  The  contents  of  the 
sterilizing  chamber  should  be  subjected  to  steam  pressure,  as  stated, 
for  from  twenty  to  thirty  minutes,  when  the  contents  of  the  chamber 
will  be  sterile. 


CHAPTER  VIII 

THE    STERILIZATION   OF    SUTURE    AND   LIGATURE    MATERIAL 

GENERAL  CONSIDERATION   OF  ABSORBABLE  AND  NON- 
ABSORBABLE SUTURE  MATERIAL 

The  ideal  suture  is  one  that  is  sterile,  non-irritating,  is  absorbed  at 
the  expiration  of  the  time  required  for  healing,  and  is  of  sufRcient 
tensile  strength  to  permit  the  necessary  manipulations  without  break- 
ing. 

Ahsorhahle  suture  material  should  be  employed  to  make  apposition 
of  deeply  situated  parts.  Material  that  is  of  necessity  ultimately  to  be 
removed  may  be  employed  for  the  purpose  of  superficial  repair. 

Non-ahsorhahle  suture  material  is  not  likely  to  be  the  carrier  of 
infection,  on  the  ground  that  the  quality  that  renders  it  resistant  to 
the  action  of  the  circulating  fluids  in  the  body  also  makes  it  less  liable 
to  be  influenced  unfavorably  by  the  process  employed  in  its  steriliza- 
tion. 

As  absorbable  suture  material  undergoes  modification  of  consistence 
during  absorption,  it  presents  at  a  certain  stage  of  the  process  a  condi- 
lion  favorable  to  the  development  of  infection;  an  objectionable  state 
of  affairs,  when  a  suture  lies  in  part  upon  the  skin,  which  would  argue 
fop  the  emplojinent  of  non-absorbable  suture  material  when  making 
repair  of  superficial  wounds. 

The  method  of  preparing  suture  material  bears  an  important  rela- 
tionship to  the  behavior  of  wounds  generally,  and  for  this  reason  the 
technic  of  its  sterilization  is  extensively  gone  into. 

ABSORBABLE  SUTURE  MATERIAL 

Catgut. — Catgut,  so-called,  would  be  an  ideal  suture  material,  were 
it  not  for  the  fact  that  it  is  difficult  to  sterilize.  It  is  not,  as  the  name 
implies,  made  from  the  intestine  of  the  cat,  but  is  obtained  from  the 
small  intestine  of  the  sheep  and  goat.  It  is  obtainable  in  the  market 
dry  and  of  varying  thickness.     The  diameter  of  the  product  is  desig- 

95 


96 


WOUNDS 


nated  by  numbers,  i.  e.,  00,  0,  1,  2,  and  3 ;  a  somewhat  arbitrary  classi- 
fication, as  the  product  varies  considerably  in  diameter.  However,  but 
little  experience  is  required  to  minimize  the  discrepancies  in  this  con- 
nection. 

Catgut  is  the  natural  habitat  of  bacteria,  which  exist  throughout  its 
entire  thickness,  so  that  sterilization  involves  penetration  of  its  entirety 
by  a  process  that  does  not  destroy  its  tensile  strength. 

The  process  of  sterilizing  catgut  is  a  complicated  one,  and  unless 
special  apparatus  is  employed,  an 
unfavorable,  and,  indeed,  a  fatal 
outcome  obtains,  as  the  result  of 
error  in  technic.  For  sterilization 
each  string  is  coiled  in  the  manner 
shown  in  Fig.  60.  Of  the  large  num- 
ber of  methods  proposed  for  the 
sterilization  of  catgut  for  ligatures 
and  sutures,  none  is  as  certain  and 
universally  applicable  as  the  so- 
called  cumol,  dry  sterilization 
method. 

Three  kinds  of  prepared  catgut 
will  be  described:  The  plain,  the 
chromicized,  and  the  iodized.  The 
two  former  necessitate  the  removal 
of  the  fats  from  the  raw  material, 
the  latter  does  not. 

Plain  Catgut. —  This  is  more 
readily  absorbed  than  the  chromic; 
it  is  more  pliable  and,  consequently, 
ties  a  closer  knot  than  chromic, 
though  the  latter  is  stronger,  re- 
mains in  situ  longer,  and  is  the  more  easily  handled.  The  exact  place 
that  iodin  catgut  occupies  is  dilHcult  to  state.  In  its  preparation  it 
frequently  undergoes  a  change  which  lessens  its  tensile  strength  —  a 
serious  objection,  but  one  that  does  not  apply  strongly  in  hospital 
practice,  where  it  is  used  soon  after  preparation.  The  simplicity  of 
its  preparation  appeals  in  this  connection.  In  a  general  way,  it  may 
be  said  that,  properly  prepared,  plain  and  chromic  gut  meets  every 
indication. 


Fig 


-Catgut  Looped  and  Eeady 
FOR  Sterilization. 


STERILIZATION  OF  SUTURE  MATERIAL  97 

Removal  of  fats  from  catgut :  A  number  of  coils  of  gut,  three  feet 
in  length  (Fig.  60),  are  placed  in  an  Erlenmeyer  flask  and  submerged 
in  ether.  It  is  desirable  to  allow  the  gut  to  lie  thus  for  a  month, 
changing  the  ether  at  intervals,  with  the  view  of  decanting  the 
extracted  fats  held  in  solution,  and  substituting  fresh  ether,  which 
permits  of  additional  exhaustion  of  the  fats.  If  facilities  for  this  be 
not  available,  the  flask  containing  the  submerged  gut  is  exposed  to 
steam  and  the  fats  are  boiled  out.  The  top  of  the  flask  is  connected 
with  a  condenser,  to  save  the  vaporized  ether,  which  should  be  redis- 
tilled before  u^ing  a  second  time.  The  ether  holding  the  fat  in  solu- 
tion is  poured  off  while  hot,  fresh  ether  being  added  at  intervals  for 
one  hour.  A  small  quantity  of  fat  remains  in  the  gut  after  the  ether 
extraction  is  completed.  This  residual  fat  may  be  removed  by  boiling 
the  gut  in  alcohol  —  preferably,  absolute  alcohol.  A  larger  proportion 
than  5  per  cent  of  water  in  the  alcohol  will  cause  the  gut  to  swell, 
tangle,  and  lose  its  tensile  strength. 

Chromic  Gut. — The  fats  are  removed  as  described,  and  the  gut  is 
wound  on  bobbins  or  arranged  in  coils  and  submerged  in  the  follow- 
ing solution : 

Potass,  bichromat gr.  xxii  ss 

Aq.  dest ozs.  xv 

Dissolve  and  add : 

Glycerin dr.  ii  ss 

Acid  carbolic    dr.  ii  ss 

The  gut  is  allowed  to  remain  in  this  solution  for  thirty  hours,  when 
it  is  removed,  tiglitl}'  stretched  on  a  board,  and  allowed  to  dry  in  the 
air  or  in  an  oven  at  a  temperature  of  113°F.  (45°C.).  "When  the  gut 
is  dry,  it  is  again  coiled.  This  chemical  treatment  makes  the  gut 
strong  and  hard,  so  that  it  may  be  maintained  in  the  tissues  for 
varying  periods  of  time,  without  undergoing  absorption.  Sterilization 
is  not  achieved  in  this  U'aij;  indeed,  the  hardening  of  the  material 
makes  this  less  readily  accomplished.  The  process  of  sterilization 
about  to  be  described  renders  the  gut  more  pliable. 

Sterilization  of  catgut. —  The  destruction  of  bacteria  in  gut  by  the 
action  of  chemical  agents,  such  as  immersion  in  a  solution  of  biniodid 
of  mercury  in  chloroform,  bichlorid  of  mercury  in  alcohol,  etc.,  has 
been  employed  for  many  years  with  seemingly  desirable  results.  More 
recent  investigations  have  shown  that  the  chemical  treatment  of  catgut 
does  not  achieve  sterility;  therefore,  a  description  of  these  methods  of 


98 


WOUNDS 


procedure  is  omitted.    It  is  submitted,  that  the  heat-cumol  method,  if 
properly  executed,  absolutely  sterilizes  both  plain  and  chromic  gut. 

Sterilization  of  catgut  in  cumol:     The  apparatus  used  for  drying 
and  cumolizing  catgut  (Fig.  61)  is  described  as  follows: 

The  sterilizer  is  made 
throughout  of  brass  and 
bronze,  nickel  plated. 
The  interior,  or  cumol  re- 
taining cylinder,  is  six 
inches  in  diameter  and 
eight  inches  deep.  The 
outer  cylinder  is  eight 
inches  in  diameter  and 
nine  and  one  half  inches 
deep,  providing  for  an  in- 
tervening space  of  one 
inch  all  around  between 
the  two,  and  one  and  one 
half  inches  from  the  bot- 
tom of  the  outer  cylinder. 
This  space  between  the 
two  cylinders  is  com- 
pactly filled  with  white 
sand.  The  top  of  the 
sterilizer  articulates  close- 
ly with  the   cast  bronze 

faced  ' '  ring  secured  to 
the  upper  end  of  the  re- 
taining cylinder,  forming 
a  steam  tight  joint. 

The  apparatus  is  sup- 
ported on  four  legs,  which 
rest  in  a  metal  tray  as 
shown  in  the  illustration. 


Fig.  61.- 


-Apparatus  for  Sterilization  of  Cat- 
gut BY  THE  CUMOIi  METHOD. 


Heat  is  furnished  hy  means  of  a  Bunsen  burner,  though  any  other 
source  of  heat  may  be  used  for  the  purpose.  The  heat  is  directed 
against  the  bottom  of  the  outer  cylinder,  thereby  uniformly  heating 
the  quartz  bath,  and,  in  turn,  is  transmitted  to  the  cumol.  The  cumol 
sterilizer  is  provided  with  a  draw-off  valve,  a  thermometer,  and  a 
burner  consistent  with  the  available  fuel. 


STERILIZATION  OF  SUTURE  IVIATERIAL 


90 


The  gut,  cleansed  and  prepared  in  the  way  already  described,  is 
placed  in  the  interior  cylinder  of  the  cuinolizer  and  the  apparatus 
closed.  The  temperature  is  raised  to  176°F.  (80°C.)  and  maintained 
there  for  two  hours,  at  the  end  of  which  time  all  moisture  is  removed 
from  the  gut,  thus  preventing  its  becoming  brittle  during  the  subse- 
quent steps  of  its  preparation. 

Curnol  is  then  introduced  into  the  interior  cylinder,  submerging 
the  gut,  and  the  temperature  is  raised  to  311°F.  (155°C.)  and  main- 
tained there  for  one  hour,  when  the  cumol  is  drawn  off  through  a  tube 
attached  to  the  lower  spout  and  the  residual  cumol  is  driven  off  by 
maintaining  a  temperature  of  212 °F.  (100°C.)  for  about  two  hours. 
The  gut  is  then  removed  and  stored  in  either  glass  tubes  or  jars.  The 
gut  in  the  jars  is  covered  with  a  0.1  per  cent  solution  of  mercuric 
biniodid  in  chloroform  to  prevent  contamination  during  removal  of  a 
portion  of  the  contents. 


Fig.  62. —  Sterile  Catgut  in  Hermetically  Sealed  Glass  Tube  Broken  at 

File  Scratch. 


The  danger  of  contaminating  sterilized  catgut  stored  in  jars  is 
overcome  by  placing  the  prepared  ligature  and  suture  material  in 
hermeticalhj  sealed  glass  tubes.  The  gut  is  coiled,  or  wound  on  a 
bobbin,  placed  in  the  glass  tube  and,  after  sterilization  in  cumol,  as 
already  described,  the  tube  is  sealed  and  resterilized  at  eighteen 
pounds  of  steam  pressure  for  one  hour. 

The  glass  tube  is  scratched  near  its  middle  with  a  file  to  facilitate 
breaking,  when  the  contents  is  used  (Fig.  62).  Gut  prepared  in  this 
way  may  be  transported  without  danger  of  contamination.  The  glass 
tube  may  be  sterilized  by  boiling  at  the  time  of  the  operation. 

loDiN  Catgut. —  The  raw  gut   (neither  the  ether  nor  alcohol  bath 


100 


"WOUNDS 


is  necessary)  is  rolled  on  glass  spools  and  immersed  in  the  following 
solution : 

lodin  1  per  cent. 

Potass,  iodid  1  per  cent. 

Sterile  water  98  per  cent. 

The  gut  is  allowed  to  remain  in  the  solution  for  eight  days,  when  it 
is  ready  for  use.  As  a  rule,  it  is  preserved  in  a  glass  jar,  though  it 
may  be  put  in  tubes  submerged  in  the  solution  of  iodin  mentioned 
(Fig.  62).  If  iodin  catgut  is  preserved  in  a  sealed  glass  tube,  the 
latter  must  be  sterilized  in  a  cold  antiseptic  solution  immediately 
before  using.  If  the  tube  is 
boiled  with  the  instruments, 
the  catgut  is  disintegrated 
and  becomes  friable  and  use- 
less. 

Kangaroo  Tendon. —  As 
the  name  implies,  kangaroo 
tendon  is  made  from  the 
tendon  of  the  kangaroo. 
As  it  is  not  the  natural  habi- 
tat of  bacteria,  as  is  catgut, 
it  may  be  sterilized  by  im- 
mersion in  antiseptic  fluids. 
Heat  disintegrates  it,  there- 
fore it  is  prepared  in  the 
following  way: 

The  tendon  is   extracted 
with   ether,   which  removes 
the  fats,  immersed  in  a  3  per 
cent    solution    of    camphor 
in   albolin   containing  mer- 
curic bichlorid  in  the  proportion  of  1:4000,  in  which  it  is  soaked 
for  a  week ;  it  is  then  put  in  a  glass  tube  similar  to  those  used  for 
catgut,  submerged  for  a  second  time  in  a  fresh  mercury  and  albolin 
mixture,  and  the  tube  sealed. 


Fig.  63. —  Silkworm  Gut  in  Hank, 


NON-ABSORBABLE  SUTURE  MATERIAL 

Silkworm  Gut. —  Silkworm  gut  consists  of  the  fiber  drawn  from  the 
body  of  the  silk  worm,  killed  just  as  it  is  about  to  spin  its  cocoon. 


STERILIZATION  OP  SUTURE  MATERIAL  101 

It  is  obtainable  in  the  market  in  strands  about  fourteen  inches  in 
length  (Fig.  63).  It  is  readily  sterilized  by  boiling^  which,  together 
with  its  smooth  surface  and  great  tensile  strength,  renders  it  a  useful 
agent  in  situations  where  the  use  of  non-absorbable  ligature  material  is 
indicated.  For  convenience  silkworm  gut  may  be  preserved  in  sealed 
glass  tubes  similar  to  the  one  shown  in  Fig.  62. 

Silk. — Silk  for  sutures  and  ligatures  is  obtainable  in  the  market  in 
two  forms,  twisted,  and  braided ;  the  twisted  is  used  for  fine  sutures, 
and  the  braided,  for  retention  sutures  and  for  deligating  large  pedicles ; 
it  is  sterilized  by  boiling  for  ten  minutes  in  a  1  per  cent  aqueous 
solution  of  sodium  carbonate. 

Hagler^  seems  to  have  shown  that  sterilization  by  heat  is  not 
sufficient,  claiming  that  the  drawing  of  the  material  through  the 
hands  and  the  manipulations  necessary  in  threading  the  needles 
cause  fertilization  of  the  product ;  however,  this  is  true  of  all  suture 
and  ligature  materials.    It  would  seem  that  silk,  because  of  its  nature. 


Fig.  64. —  Pagenstecher  Thread. 

is  more  readily  fertilized  during  manipulation,  than  is  smooth  suture 
material.  It  is  suggested  that  the  silk  be  boiled  immediately  be- 
fore the  operation,  rather  than  sterilized  in  soda  solution  and  pre- 
served, wound  on  bobbins,  submerged  in  antiseptic  solutions ;  a  method 
of  procedure  probably  safer  than  placing  reliance  upon  impregnation 
of  the  material  with  mercury. 

Pagenstecher  Thread. —  Pagenstecher  thread  is  a  linen  thread  that 
has  been  dipped  in  a  solution  of  celluloid.  It  is  readily  obtained  in 
the  market  in  skeins  (Fig.  64).  It  is  strong,  of  small  diameter, 
readily  sterilized,  and  easily  handled.  It  does  not  lose  its  slight 
stiffness  when  saturated  with  solutions,  and  consequently  does  not 
ravel,  as  does  silk,  when  wet.  It  is  sterilized  by  boiling,  and  may  be 
boiled  for  practically  an  indefinite  period  of  time  without  damage. 

Horsehair. —  Horsehair  is  obtained  from  the  tail  of  the  horse ;  it  is 
then  washed  with  soap  and  water  and  boiled  for  an  hour  in  95  per 
cent  alcohol,  when  it  is  ready  for  use.    It  may  be  preserved  in  a  glass 


102  WOUNDS 

jar,  or  in  glass  tubes  (Fig.  62)  submerged  in  alcohol.  It  is  very  easily 
handled,  does  not  ravel,  and  because  of  its  fineness  may  be  threaded 
on  exceedingly  small  needles.  It  is  used  in  cases  where  scarring  is  to 
be  avoided,  such  as  repair  of  harelip,  and  other  plastic  operations  of 
the  face. 

Silver  and  Gold  Wire. —  Silver  and  gold  wire  are  used  to  appose 
fragments  of  bone.    They  are  readily  sterilized  by  boiling. 

BIBLIOGRAPHY 

1.     Hagler.     Chir.  kong.  Vehr.  1901,  ii. 


CHAPTER  IX 


WATER  AND  CLP]AXSIXG  SOLUTIONS 


WATER 

Sterilization  of  Water. —  Absolutely  sterile  water  is  necessary  in 
surgical  technic.  For  purposes  of  lavage,  water  need  not  be 
chemically  pure,  though  when  it  is  used  as  a  vehicle  for  antiseptics 
it  should  not  contain  agents  likely  to  cause  precipitation.  The  pres- 
ence, in  water,  of  foreign  bodies,  though  they  be  sterile,  is  objectionable 

in  solutions  used  for  intravenous  in- 
jections, for  obvious  reasons.  Wa- 
ter, when  made  available  from  a 
container  in  which  it  has  been  ster- 
ilized immediatel}^  before  its  use, 
achieves  the  object.  All  other  meth- 
ods of  water  sterilization  are  faulty. 
Distilled  water  possesses  the  advan- 
tage of  transparency,  though  the  ap- 
paratus necessary  for  distillation  is 
not  readily  kept  sterile,  and  the 
simple  distillation  of  water  does  not 
achieve  sterility.  Muddy  water  may 
be  sterile,  though  the  foreign  ma- 
terial must  be  removed  by  filtration. 
However,  in  an  emergency  it  would 
be  wiser  to  use  cloudy  sterilized  wa- 
YiG.  6.-5.— Apparatus  for  Sterilizing  ^er  than  to  act  on  the  notion  that, 
Water  Under  Pressure.  because  water  is  clear,   it  is  clean. 

For  use  in  surgeon's  office  or  small  ^-.j.  .        .  -,    ,      r>T, 

dispensary.  When  water  IS  used  to  fill  cavities 

for  examination,  it  is  advantageous 
both  to  distill  and  to  sterilize  it.  In  hospitals,  distilling  plants  of 
large  capacity  are  installed,  making  transparent  water  available, 
which,  after  sterilization,  may  be  used  for  all  purposes. 

103 


104 


WOUNDS 


Apparatus  for  Sterilizing  Water. — For  the  purpose  of  sterilizing 
water,  two  kinds  of  apparatus  are  available :  One  which,  subjects  the 
water  to  a  temperature  of  212°F.  (100°C.),  and  another  which  makes 
possible  the  use  of  a  temperature  higher  than  the  boiling  point;  the 
latter  being  the  more  effective  of  the  two. 


Fig.  66. — Apparatus  for  Sterilizing  "Water  in  Large  Hospital. 


For  ordinary  purposes,  in  minor  or  emergency  surgery,  water  boiled 
in  a  clean  vessel  for  twenty  minutes,  and  used  immediately,  meets  the 
indication.  For  the  surgeon 's  office,  and  in  dispensaries,  the  apparatus 
shown  in  Fig.  65  may  be  advantageously  used. 

The  apparatus  shown  (capacity  two  gallons)  subjects  the  water  to 


WATER  AND  CLEANSING  SOLUTIONS  105 

a  pressure  of  fifteen  pounds  to  the  square  inch.  To  fill,  the  water  is 
poured  into  the  funnel  and  the  quantity  noted  on  the  water  gauge ; 
the  burner  beneath  is  then  lighted,  and  the  water  heated  until  steam 
issues  from  the  funnel,  when  the  valve  is  closed  by  screwing  down. 
Sufficient  pressure  will  then  be  generated  to  release  the  safety  valve, 
which  is  set  at  fifteen  pounds,  or  250°F.  (121°C).  Tliis  temperature 
is  maintained  for  from  fifteen  to  twenty  minutes. 

The  objection  to  the  steam  pressure  sterilizer  just  described  is, 
that  the  water  is  liable  to  be  too  hot  or  too  cold  for  immediate  use. 
This  is  obviated  in  the  apparatus  shown  in  Figs,  66  and  67,  which  has 
one  tank  fitted  with  an  inner  coil  connected  with,  a  cold  water  tap, 
an  arrangement  permitting  modification  of  degree  of  temperature 
within  the  desired  range  as  indicated  by  a  thermometer  affixed  to  the 
apparatus. 

The  apparatus  is  operated  as  follows  (Fig.  66)  :  The  water  supply 
is  connected  to  filter  M  at  point  E.  The  filter  itself  consists  of  a 
porous  stone  bougie,  which  can  be  taken  out  of  the  metal  mantle, 
cleansed,  and  replaced  by  releasing  top  which  is  held  tight  to  the 
cylinder  by  a  heavy  metal  clamp  (N) . 

There  are  two  outlets  FF  for  the  filtered  water  leading  into  the  two 
tanks;  both  are  provided  with  valves.  These  valves  may  be  opened 
at  the  same  time,  or  the  tanks  filled  in  sequence  as  indicated  by  the 
gauge  gla.sses  KK,  following  which  the  water  supply  valve  E  leading 
to  the  filter  and  the  two  valves  FF  are  closed. 

The  water  is  now  heated  until  the  steam  pressure  safety  valve  W 
(on  the  domes  of  the  tanks)  releases,  which  occurs  at  fifteen  pounds 
pressure  (250°F.  —  126.66°C.) .  The  water  is  kept  at  this  temperature 
from  twenty  to  thirty  minutes,  whereupon  the  gas  heaters  GG  are  shut 
off,  or  in  the  case  of  a  steam-heated  apparatus,  the  high  pressure  boiler 
steam  is  shut  off  by  closing  valves  AA  and  BB. 

Cold  water  is  now  turned  into  the  coil,  in  tank  marked  cold.  Fig. 
66,  at  point  D,  and  allowed  to  exit  at  point  C.  "Within  from  ten  to 
twenty  minutes  the  boiling  sterile  water  in  the  tank  will  have  been 
cooled  to  wathin  a  few  degrees  of  temperature  higher  than  that  of  the 
water  used  for  cooling.  Contamination  of  the  water  by  the  entrance 
of  atmosphere  is  prevented  by  the  air  filtering  valves  XX  which  are 
filled  with  absorbent  cotton.  As  water  is  drawn  out  of  the  tanks,  the 
air  enters  through  the  bacteriological  filters  XX,  the  absorbent  cotton 
in  which  should  be  frequently  renewed. 

The  tank  marked  hot  (Fig.  66)  has  no  cooling  coil,  and  its  contents 


106 


WOUNDS 


II'         r 


c: 


i'  ;•. 


(fpivn-^i       «y%nf^ 


£ 


h  ^ 


4@3@) 


M 


V 


--=ig3=KS  ^Y^ 


Wjtx^- 


Cojl 


^ 


thekny-schee:r£Rco^ 

N.Y 


Fig.  67. —  Sectional  A^iew  of  Apparatus  Shown  in  Fig.  CG. 


WATER  AND  CLEANSING  SOLUTIONS  107 

is  allowed  gradually  to  cool;  By  mixing  water  drawn  from  both  tanks, 
any  desired  degree  of  temperature  may  be  obtained.  The  temperature 
of  the  water  in  the  tanks  is  indicated  by  the  thermometer  H. 

As  stated,  water,  though  clear  after  filtration,  becomes  cloudy  when 
boiled  under  pressure.  Gradually  the  cloudiness  forms  precipitates 
which  settle  on  the  bottom  of  the  tanks ;  to  draw  these  off,  drain  cocks 
are  provided  flush  with  the  lowest  points  in  the  bottom  of  the  cylinders. 
The  draw-off  cocks,  for  sterile  water,  in  the  front  of  the  tanks  are 
located  about  two  inches  above  the  bottom. 

CLEANSING  SOLTJTIONS 

Cleansing  solufions  may  be  divided  into  those  that  mechanically 
dislodge  offending  material  .from  wound  surfaces,  at  the  same  time 
destroying  bacteria  by  chemical  action  (antiseptic  solutions),  and, 
those  which  act  only  mechanically. 

Antiseptic  solutions,  as  far  as  their  bactericidal  efficiency  is  con- 
cerned, are,  as  already  stated  (p.  59),  of  doubtful  utility.  It  is  prob- 
able that  antiseptic  solutions  should  be  us.ed  in  the  treatment  of  fresh 
wounds  only  when  especially  indicated,  that  is,  in  cases  where  the 
solution  of  continuity  of  the  part  has  been  inflicted  by  an  agent  known 
to  be  infected. 

The  emplo^Tuent  of  the  term  antiseptic,  as  applied  to  the  destruc- 
tion of  bacteria  concerned  in  the  production  of  the  processes  conse- 
quent to  the  invasion  of  wounds  by  bacteria,  is  unfortunate,  since  the 
process  is  not  necessarily  one  of  sepsis ;  indeed,  the  infection  of  wounds 
followed  by  the  most  severe  manifestations,  even  death,  is  not  accom- 
panied by  the  formation  of  pus ;  however,  the  term  has  been,  and  is 
still,  so  largely  used,  that  it  is  regarded  as  expedient  to  continue  its 
employment  here. 

Antiseptic  solutions  of  sufficient  strength  to  destroy  bacteria  have  a 
deleterious  effect  upon  tissues.  As  a  general  rule,  they  are  effective 
as  bactericides  only  after  prolonged  contact  with  microorganisms. 
Their  most  valuable  office  is  to  cleanse  the  skin  of  the  patient,  the 
hands  of  the  surgeon  and  his  assistants,  and  the  instruments  used  in 
infected  cases  during  operations. 

Carbolic  acid  is  widely  used  as  a  bactericidal  agent;  it  is  cheap, 
readily  obtained,  and  effective  when  used  in  strong  solution.  When 
undiluted,  it  is  caustic  in  its  action,  though  this  maj'-  be  neutralized 
by  the  immediate  application  of  alcohol  in  quantity. 


108  WOUNDS 

111  solution,  carbolic  acid  is  used  iu  the  proportion  of  1 :20  for 
cleansing  the  skin,  for  immersion  of  instruments,  and  for  the  purpose 
of  saturating  towels  used  contiguous  to  the  operative  field  in  infected 
cases.  It  is  comprehensible  that  a  towel  sterilized  by  heat  is  more 
readily  contaminated  by  contact  with  infective  material  than  is  one 
saturated  with  carbolic  acid  after  heat  sterilization. 

Mercury  is  perhaps  the  most  widely  used  antiseptic.  It  is  employed 
in  solution  of  1 :1,000  to  1 :10,000.  It  is  effective,  inodorous,  and  will 
keep  indefinitely.  It  is,  however,  poisonous,  and  should  not  be  kept  in 
prolonged  contact  with  raw  surfaces,  nor  retained  in  large  cavities, 
as  mercurialization  is  apt  to  result.  The  salts  of  mercury,  chiefly  the 
bichlorid,  are  used  combined  with  sodium  bicarbonate  to  avoid  chem- 
ical change  in  the  preparation  and  to  enhance  solubility. 

Zinc  chlorid,  etc. —  Solutions  of  chlorid  of  zinc,  1 :15 ;  iodin,  1 :500 ; 
sulphocarbolate  of  zinc,  1 :80 ;  a  saturated  solution  of  boracic  acid, . 
1  :2 ;  or  a  saturated  solution  of  iodoform  in  ether  have  been  used  for 
cleansing  wounds.  They  are  rarely  used  for  cleansing  the  operative 
field,  and,  while  possessed  of  slight  bactericidal  action,  are  not  as 
effectual  in  this  connection  as  the  agents  mentioned  above.  However, 
they  may  be  advantageously  employed,  in  concentrated  form,  in  the 
treatment  of  postoperative  wound  infection. 

Thiersch's  fluid  is  composed  of  one  grain  of  salicylic  acid  and  six 
grains  of  boric  acid  to  the  ounce  of  water.  As  can  be  seen  from  its 
composition,  it  is  not  bactericidal.  It  is  used  for  cleansing  serous  and 
mucous  membranes,  such  as  the  peritoneum,  joint  cavities,  the  con- 
junctiva, and  the  mucosa  of  the  mouth,  bladder,  etc.  It  should  be 
made  immediately  before  using. 

Peroxid  of  hydrogen  consists  of  water  with  an  added  atom  of 
oxygen  J  the  latter  is  but  unstably  associated  and  is  given  up  when 
the  preparation  comes  in  contact  with  the  tissues.  Peroxid  of  hydro- 
gen does  not  possess  bactericidal  qualities.  The  active  effervescence 
w^hich  takes  place  when  the  fluid  is  in  contact  with  the  tissues  cause* 
penetration  of  the  liquid  into  remote  portions  of  the  wound,  and 
mechanically  dislodges  offending  substances,  without  giving  rise  to 
irritation.  Heat  destroys  its  efficacy ;  therefore,  it  should  be  only 
slightly  warmed  before  using  by  immersing  the  container  in  hot 
water.  When  introduced  into  cavities  with  small  openings,  ample  pro- 
vision should  be  made  for  the  escape  of  the  liquid,  as  the  effervescence 
is  likely  to  cause  invasion  by  infective  material  of  the  surrounding 
healthy  tissues. 


WATER  AND  CLEANSING  SOLUTIONS  109 

Pladn  sterile  water,  when  brought  in  contact  with  the  tissues, 
extracts  certain  constituents  which  are  essential  to  them,  and  causes 
a  decoloration  of  both  traumatized  and  normal  membranes.  The  part 
played  by  the  inorganic  constituents  of  the  body,  in  nutrition,  is  un- 
known, yet  they  are  undeniably  essential  to  life.  Mechanically,  sterile 
water  is  an  ideal  cleansing  fluid,  as  it  is  obtainable  in  unlimited  quan- 
tity, and,  by  the  process  of  dilution,  removes  infective  substances 
from  the  tissues.  However,  it  seems  to  be  avid  for  something  to  hold 
in  solution,  a  quality  which  is  objectionable  in  surgical  teehnic. 

Saline  solution  overcomes,  to  a  considerable  extent,  the  objections 
mentioned  in  connection  wuth  sterile  water.  It  is  made  by  dissolving 
in  a  quart  (L)  of  filtered  water,  sterilized  at  a  temperature  of  240°F. 
(115. 5°C.)  a  dram  and  a  half  (6.0  gram.)   of  sodium  chlorid. 

The  sodium  chlorid  should  be  chemically  pure  and  sterilized  by 
heat.  The  solution  may  not  be  regarded  as  harmless  when  chemically 
pure  sodium  chlorid  is  dissolved  in  sterile  water,  but  should  be 
filtered  carefully  and  again  sterilized  by  heat. 

Saline  solution  may  be  permitted  to  remain  in  contact  w^ith  living 
tissues  for  a  considerable  period  of  time  without  deleterious  effect. 
The  solution  has  no  bactericidal  qualities,  its  usefulness  being  restricted 
to  the  mechanical  cleansing  of  wounds.  It  is  largely  used  for  the 
purpose  of  washing  clean  wounds,  especially  those  involving  serous 
cavities  and  mucous  membranes.  "When  infection  is  present  saline 
solution  should  not  be  used  except  for  the  occasional  intermittent 
removal  of  antiseptic  solutions  and  wound  secretions.  It  is  probable 
that,  when  infection  exists,  the  prolonged  contact  of  saline  solution 
with  the  wound  area  favors  the  development  of  bacterial  flora. 


CHAPTER  X 
THE   OPEEATING  ROOM 

Hospital  Operating  Room. —  In  hospitals  and  sanatoria,  special 
chambers  are  arranged  for  the  purpose  of  performing  surgical  opera- 
tions. In  private  practice  it  is  not  possible  to  establish  the  favorable 
conditions  found  in  these  institutions. 

It  is  intended  to  describe  first  the  operating  room  arrangement 
which  is  most  desirable,  and  which  exists  in  well  equipped  institutions, 
and  later  to  take  up  the  subject  as  applied  to  private  practice,  where 
modification  of  this  is  necessary ;  thus,  while  setting  a  standard,  show 
how  this  may  be  modified  under  certain  circumstances  with  satis- 
factory outcome.  In  making  this  standard  of  the  most  desirable 
arrangement,  it  is  intended  that  it  should  be  used  for  purposes  of 
comparison  by  the  operator  who  works  in  a  private  residence,  that  the 
best  may  be  approached  as  closely  as  possible,  though  this  involves 
considerable  modification  as  regards  the  appurtances  emploj'ed. 

The  operating  room  should  be  located  at  the  top  of  the  building, 
be  well  ventilated,  with  windows  on  three  sides,  and  a  skylight  so 
situated  that  its  light  falls  on  the  operating  table  at  an  angle  which, 
at  the  same  time,  permits  of  lateral  illumination  from  the  windows. 
That  is,  the  light  from  the  side  windows  should  fall  on  the  perineum 
when  the  patient  is  in  the  lithotomy  position,  and  at  the  same 
time  make  the  overhead  light  available,  w'ithout  changing  the  location 
of  the  table,  when  the  patient  is  placed  in  the  Trendelenburg  position. 
The  skj'light  should  be  permanently  sealed,  as  the  ropes  or  reach  rods 
necessary  to  open  and  close  M^ndows  will,  when  manipulated  during 
an  operation,  shake  dust  into  the  operative  field.  As  moisture  gathers 
on  the  under  surface  of  a  skylight,  it  should  be  furnished  with  a 
gutter  at  its  dependent  portion. 

The  floor  of  the  operating  room  should  be  tiled;  the  tiles  set  in  four 
inches  of  cement  and  have  a  smooth  surface  to  permit  cleansing  and 
to  avoid  the  absorption  of  foreign  .substances  such  as  blood,  pus, 
etc.,  which  invariablj^  find  their  way  to  the  operating  room  floor  during 

110 


THE  OPERATING  ROOM 


111 


surgical  manipulations.    The  floor  should  be  graded  to  a  central  drain. 
The  junction  of  the  floor  and  walls  should  be  made  by  means  of  curved 


f 


! 


I 


YiG.  68.—  Operating  Room  Utensil  Sterilizer. 

tiles;  the  walls  tiled  to  a  height  of  six  feet  and  their  upper  portion 
made  of  cement  which  is  covered  with  enameled  paint.    This  arrange. 


112 


WOUXDS 


ment  permits  thorough  cleansing  of  the  chamber,  for  which  pur- 
pose soda  and  green  soap  solution  may  be  advantageously  used,  and 
allows  of  subsequent  lavage  by  means  of  a  garden  hose. 

Aktificial  Illumixatiox. —  Artificial  illumination  is  best  accom- 
plished by  means  of  electricity,  governed  by  a  side  wall  switch,  thus 
avoiding  the  shaking  down  of  dust,  the  outcome  of  manipulations  at 
the  chandelier.  The  chandelier  should  be  furnished  with  a  reflector 
and  the  lighting  bulbs  grouped  in  a  cluster,  to  avoid  the  throwing  of 


Fig.  69. —  Operating  Table  (which  ^ieets  most  ecdicatioxs). 


confusing  shadows  on  the  operatiA-e  field.  The  source  of  light  should 
be  placed  sufficiently  high  above  the  table  to  avoid  contact  with  the 
operator  during  manipulations. 

The  apparatus  necessary  for  the  sterilization  of  water  and  dressings 
should  be  installed  in  a  chamber  contiguous  to  the  operating  room. 
The  water  from  the  sterilizer,  however,  should  be  piped  into  the 
operating  room  so  that  the  supply  may  be  readily  replenished.  Before 
sterilization,  the  dressings,  sponges,  etc.,  are  packed  in  convenient 


THE  OPERATING  ROO:\I 


113 


parcels,  which  permits  transportation  to  the  scene  of  operation 
without  danger  of  contamination.  The  instrument  and  the  utensil 
sterilizers  (Fig.  68)  should  be  located  in  the  operating  room,  as  con- 
ditions constantly  arise  making  necessary  the  immediate  and  prompt 
resterilization  of  appurtenances  accidentally  contaminated  during 
an  operation. 

The  Operating  Table. —  The  table  here  described  (Fig.  70)  per- 
mits placing  the  patient  in  a  variety  of  positions,  and  may  be  so 
adjusted  as  to  make  readily  accessible  to  the  surgeon's  manipulations, 
the  various  portions  of  the  body.  Its  employment  should  make  un- 
necessary the  use  of  tables  designed  for  special  purposes,  except  in 

institutions  devot- 
ed to  the  care  of 
special  classes  of 
cases,  where  sim- 
plicity in  construc- 
tion is  desirable. 

The   sections    of 
the   table   top   are 
hinged,  and  so  ar- 
ranged   that    they 
may  be  easily  ad- 
justed   while    the 
operation      is      in 
progress.     The  en- 
tire table  top  may 
be   raised   or  low- 
ered by  means  of  a  pedal  and  a  hydraulic  pump  located  in  the  base ; 
the  latter  locks  automatically  upon  release  of  pressure  on  the  pedal, 
which  is  controlled  by  the  narcotist. 

Fig.  70  shows  the  table  top  arranged  to  make  the  gall  bladder  acces- 
sible, when  the  patient  is  supine,  and  to  lengthen  the  iliocostal  space 
when  the  lateral  position  is  employed  during  kidney  operations. 
Operations  upon  the  neck,  lary-nx,  thrj'oid  gland,  ligature  of  the  sub- 
clavian artery,  etc.,  are  facilitated  by  placing  the  patient  upon  the 
table  in  the  position  shown  in  Fig.  71.  Fig.  72  shows  the  table  with  its 
various  appliances,  i.  e.,  adjustable  heel  stirrups,  leg  holder,  foot  rest, 
support  for  the  body  when  tilted  laterally,  adjustable  shoulder 
supports,  and  narcotist's  screen  frame.     In  addition  to  this,  the  dif- 


FiG.  70. —  Operating  Table  for  Large  Hospitals; 
Arranged  for  Gall  Bladder  or  Kidney  Opera- 
tions. 


114 


WOUNDS 


ferent  positions  in  which  the  table  may  be  placed  are  shown  in 
Fig.  73. 

A  diagramatic  presentation  of  a  convenient  method  of  arranging 
the  tables  in  the  op- 
erating room,  and  ^Z"^'  " 
also  an  effective 
manner  of  posting 
the  assistants,  to 
serve  best  the  con- 
tingencies arising  in 
operative  work,  is 
shown  in  Fig.  74.' 

The  Instrument 
Table.— This  table 
should  be  covered 
with  a  sterile  sheet, 
and  the  instruments, 
after      sterilization, 

arranged  upon  it.  A  pan  of  sterile  water  of  moderate  temperature  is 
placed  beside  the  instruments  for  the  purpose  of  cooling  them,  after 
they  are  removed  from  the  boiling  soda  solution. 


Fig.  71. —  Table  Arranged  for  Operations  on  Xeck. 


^^ 


KNY-SCHEERER  CORR 


Fig.   72. —  Table  SnowiNG  Various  Fittings,   Including 
Wheels  for  Adjustment  op  the  Several  Positions. 


THE  OPERATING  ROOM 


115 


An  adjustable  tray  with  the  instruments  in  immediate  use  arranged 
as  shown  in  Fig.  75,  may  be  placed  close  to  the  operator. 

Table. —  The  dressing  table,  upon  which  are  sterile  towels,  sheets, 
etc.,  should  be  ample  for  the  purpose. 


WITH    hjARrLCY    Foot   l^csy 


Fig.   73. —  Diagram   of  Various   Positions   Attainable   by   Table   Shown  in 

Figs.  70,  71,  72. 


The  Operating  Room  in  Private  Practice. —  Sterile  material  for  wipes, 
dressings,  sterile  towels,  and  sheets,  packed  in  impervious  packages, 
are  obtainable  in  the  market.    If  the  surgeon  has  not  at  his  command 


116 


WOUNDS 


apparatus  which  will  sterilize  this  class  of  material  with  certainty, 
it  would  be  best  obtained  in  the  market.    Towels  and  sheets  are  per- 


pELVic  ANP  Plastic 


Fig.   73. —  Diagram   of  Various   Positions  Attainable    jy  Table  Shown  in 

Figs.  70,  71,  72. 

haps  less  readily  obtainable  than  dressings ;  however,  favorable  results 
as  regards  asepsis  in  private  practice  may  be  achieved  by  baking 


THE  OPERATING  ROOM 


117 


TabU  for  Buint,  Ac 


laiH,  Q 


O'"** 


Chitf  Assistant. 

o 


towels,  sheets,  and  gowns  in 
the  kitchen  oven,  followed 
by  immersion  in  bichlorid 
solution  (1:1,000)  for  twen- 
ty minutes.  This  necessi- 
tates the  wearing  of  a  wet 
gown,  a  minor  objection, 
though  one  that  cannot  be 
overcome,  as  the  process  of 
baking  does  not  accomplish 
sterility. 

The  chamber  selected  for 
the  operation  should  be  well 
lighted,  and  the  necessary 
apparatus  distributed  so  as 
to  interfere  as  little  as  pos- 
sible with  its  availability. 

If  the  room  is  to  be  pre- 
pared on  the  same  day  that 
the  operation  is  performed, 
care  must  be  taken  not  to 

agitate  more  dust  than  will  settle  before  the  surgeon's  work  begins. 

In  this  instance  the  curtains,  shades,  furniture  and  pictures  should  be 


Span  Instnunents. 


Fig.  74. —  Diagram  of  Arrangement  of 
Apparatus  and  Assistants  During  an 
Operation. 


Pig.   75. — Adjustable  Tray  Co^1:RED  wttii   Sterile   Towel,  Holding  Instru- 
ments EEADY  for  liniEDIATE  USE. 


118 


WOUNDS 


carefully  manipulated,  and  where  possible,  wiped  with  a  damp  cloth 
before  being  removed  from  the  chamber.  Fixed  floor  covering,  such 
as  carpet,  should  not  be  removed,  but  may  be  covered  with  sheets 
dampened  with  mercuric  chlorid  (1:1,000).  The  walls  should  be 
gently  wiped  with  gauze  moistened  with  the  same  solution. 

If  sufficient  time,  before  the  operation,  is  available,  the  pictures, 
shades,    hangings,    furniture,    carpets,    ornaments,    etc.,    should    be 


Fig.    76.— Squier's    Portable    Operating    Table    Placed    in    Trendelenburg 

Position. 


removed,  the  walls  dusted,  and  the  windows  left  open  for  several 
hours,  at  the  end  of  which  time  the  windows,  doors,  and  chimney 
joints  should  be  sealed  with  gum  paper  or  adhesive  plaster  strips, 
and  the  room  impregnated  with  sulphur  fumes.  The  sulphur  should 
be  ignited  at  night,  and  the  resulting  fumes  permitted  to  remain  in 
the  chamber  until  the  following  morning,  when  the  room  is  opened, 
the  seals  removed,  and  fresh  air  admitted.  The  walls  and  ceiling  are 
wiped  with  meruric  chlorid  solution    (1:1,000),  the  floors  scrubbed 


THE  OPERATING  ROOM 


119 


Fig,  77. —  Method  of  Foldixg  Squiee  's  Table. 


with  g-reen  soap  and  hot  water,  and  the  stationary  furnishings  covered 

with  clean  sheets. 

The  Operatixg  Table. —  The  transpor- 
tation to  a  private  residence,  of  an  operat- 
ing table,  such  as  has  been  described  above, 
is  impracticable.  The  necessity  for  an  ap- 
paratus which  will  permit  the  surgeon  to 
place  the  patient  in  varying  positions  to 
make  accessible  all  portions  of  the  body, 
has  led  to  the  construction  of  a  portable 
operating  table. 

The  portable  operating  tahle  here  de- 
scribed meets  most  indications,  though 
modification  of  its  construction  to  meet  the 
contingencies   of   certain   indi^-idual   cases 

Fig.    78.— Clamps    and   IJp-  may  be   desirable.     It    is   designed   bv   J. 

RIGHTS  for  Lithotomy  Po- Bentley   Squicr   of   New   York    Citv/and 
siTioN     ON     Extemporized  .  ^  '-^  >    "^^^ 

Operating  Table.  is   constructed   of  steel  tubing  fitted  with 


120 


WOUNDS 


rack  and  pinion,  and  with  crank  for  elevating  the  top   (Fig.  76). 
For  transportation  it  is  only  necessary  to  fold  back  the  top  of  the 


Fig.  79. —  Canvas  Pack  (open). 


table,  which  is  hinged  together,  bend  the  hinges  in  the  center  of  the 
bottom  braces,  which  fold,  and  slide  the  two  ends  together  by  fold- 
ing the  side  braces 
(Fig.  77).  The  ar- 
rangement of  the 
table  permits  modi- 
fying the  position  of 
the  head,  employ- 
ment of  the  lithot- 
omy position,  and, 
of  course,  the  celi- 
otomy position. 
"When  folded  for 
transportation  the 
apparatus  measures 
6"x20"x35"  and 
weighs  twenty-eight 
pounds. 


Fig.  80.—  Canvas  Pack  (closed) . 


THE  OPERATING  ROOM  121 

In  cases  where  the  operation  involves  a  portion  of  the  body  made 
accessible  by  placing  the  patient  in  the  supine  position,  the  ordinary 
deal  kitchen  table  will  answer  the  purpose.  "When  the  lithotomy  posi- 
tion alone  is  to  be  employed,  the  deal  table  fitted  with  the  apparatus 
shown  in  Fig.  78  may  be  advantageously  used. 

The  paraphernalia  carried  to  the  scene  of  operation  are  more  con- 
veniently transported  in  a  canvas  *'pack"  (Figs.  79-80),  which  con- 
forms in  dimensions  to  the  bulk  of  material  necessary  for  a  given 
operation,  rather  than  in  the  usual  leather  bags  of  set  capacity. 

The  accessories  necessary  for  an  operation,  such  as  wash  basins,  waste 
receptacles,  side  tables,  blankets,  fresh  linen,  etc.,  are  found  in  most 
households.  The  "dominant  spirit"  in  the  house  should  be  furnished 
with  a  list  of  requirements  so  that  these  may  be  available  without  delay. 

Sterile  water  is  made  available  by  boiling  large  quantities  of  dis- 
tilled water  in  capacious  containers,  a  dipper  being  placed  in  each  one 
before  the  heat  is  applied.  The  handle  of  the  dipper  should  be  suffi- 
ciently long  to  permit  x)f  manipulation  without  contaminating  the 
water. 


CHAPTER  XI 

THE   ASEPTIC   OPERATION 

The  term  aseptic  operation  means  that  the  tissues  of  the  body  have 
been  subjected  to  surgical  manipulations  and  healing  has  taken  place 
without  the  development  of  infection.  As  already  stated,  absolute 
sterility  of  the  operative  field  and  everything  that  comes  in  contact  with 
it  is  impossible,  and,  although  most  operations  are  not  followed  by  the 
clinical  evidence  of  bacterial  contamination,  the  bacteriologist's  plat- 
inum loop  would  readily  harvest  convincing  evidence  of  its  existence, 
despite  the  fact  that  the  most  careful  and  painstaking  conformation 
to  the  so-called  rules  of  asepsis  has  been  practiced. 

This  suggests  that  the  number  of  bacteria  present  under  the  con- 
ditions stated  is  not  sufficient  to  develop  infection,  or  that  both  the 
local  and  the  constutional  resistance  of  the  patient  is  sufficient  to 
prevent  the  harmful  effects  of  the  microorganisms.  The  reduction  of 
the  bacterial  flora  to  a  minimum  is  accomplished  by  the  various 
methods  of  sterilization  already  described. 

The  constitutional  resistance  of  the  patient  is  of  course  dependent 
upon  factors  which  are,  to  a  very  limited  degree  only,  under  the  con- 
trol of  the  surgeon ;  yet  an  effort  to  render  these  serviceable  should 
not  be  neglected,  and  indeed  may  be  regarded  as  having  a  determining 
influence  with  respect  to  the  development  of  infection.  The  local 
resistance  of  tissues  may  be  considered  a  most  important  factor  in  the 
uncomplicated  repair  of  wounds  inflicted  by  the  surgeon,  and  will  be 
found  directly  proportionate  to  the  amount  of  trauma  (hauling, 
stretching,  crushing,  etc.)  inflicted  during  the  operation. 

The  presence  in  the  wound  of  blood  and  wound  secretion,  after 
repair  has  been  made,  presents  a  condition  exceedingly  favorable  to 
infection;  one  that  should  be  obviated  by  the  complete  arrest  of 
hemorrhage  (p.  36). 

Operative  procedures  without  infection  occur  when  certain  portions 
of  aseptic  technic  are  omitted,  but  this  may  be  ascribed  to  good  for- 
tune.    More  especially  in  cases  where  the  family  physician  performs 

122 


THE  ASEPTIC  OPERATION 


123 


an  operation  which  does  not  require  special  skill  (such  as  uterine 
curettage)  are  sins  of  omission  likely  to  occur.  The  notion  that  the 
simplicity  of  the  operative  procedure  makes  less  necessary  the  exercise 

of  the  complicated  technie  essen- 
tial to  the  avoidance  of  infection 
is  a  fallacious  one,  and,  unless 
the  conditions  meet  the  require- 
ments as  stated,  unfortunate  re- 
sults will  obtain. 

Befare  the  operation  the  pa- 
tient should  be  given  a  complete 
bath,  after  which  he  is  attired  in 
fresh  linen  so  arranged  as  to 
make  accessible,  with  as  little 
disturbance  as  possible,  the  part 
to  be  operated  on.  The  hair  of 
the  scalp  is  encased  in  a  sterile 
towel  or  tightly  fitting  linen  cap 
to  avoid  soiling  with  secretion  or 
vomitus  that  may  occur  while 
the  patient  is  being  narcotized. 
These  preparations  are  com- 
pleted before  the  patient  is  taken 
to  the  operating  room.  The 
transportation  to  the  operating 
room  should  be  accomplished  in 
a  manner  involving  as  little  ef- 
fort as  possible  on  the  part  of 
the  patient. 

After  the  patient  is  narco- 
tized he  is  transferred  to  the 
operating  table  (which  is  cov- 
ered with  sterile  pads),  and 
placed  in  the  position  which  will 
meet  the  requirements  of  the 
operation;  all  portions  of  the 
body,  with  the  exception  of  the  operative  field,  are  covered  with  sterile 
sheets  or  towels,  or  both,  in  such  a  manner  that  all  material  coming 
in  contact  with  the  wound  will  bo  exempt  from  the  possibility  of  eon- 


FiG.    81. 


-Attire   "Worn 

EOOM. 


IX   Operating 


124  WOUNDS 

tamination.  The  precise  arrangement  of  the  sterile  draperies  used 
to  accomplish  this  end  will  varj'  with  the  contingencies  presented. 

The  operative  field  is  cleansed  (p.  86)  by  an  assistant,  who  extends 
his  manipulations  well  beyond  the  area  of  attack ;  for  example :  Be- 
fore an  operation  on  the  foot,  the  entire  leg  is  prepared ;  in  an 
operation  involving  the  breast,  the  entire  thorax  and  half  the  back 
together  with  the  upper  arm  are  prepared.  If  furuncles,  fistulse, 
ulcers,  or  areas  of  skin  infection  be  present,  these  are  treated  with  a 
concentrated  antiseptic  and  covered  with  sterile  gauze,  held  in  place 
by  sterile  collodion.  The  area  immediately  contiguous  to  the  field  of 
operation  is  covered  with  sterile  towels,  held  in  place  at  their  inter- 
secting points  with  clamps,  or  the  like,  so  arranged  that  they  may  be 
changed  at  frequent  intervals. 

The  attire  of  the  personnel  of  the  operating  room  consists  of  sterile 
head  covering  (including  face  masks),  gowns  and  gloves;  a  type  of 
which  is  shown  in  Fig.  81. 

Instruments,  wipes,  and  suture  material  should  be  arranged  so  as 
to  be  handled  only  by  the  assistant  who  has  them  in  charge,  the 
operator,  or  his  first  as.sistant,  before  they  come  in  contact  with  the 
wound.  If  feasible,  wipes  should  be  so  located  that  they  may  be 
grasped  instantly  by  the  one  using  them  in  the  wound. 

If  possible,  the  hands,  either  bare  or  gloved,  .should  not  be  permitted 
to  enter  the  wound,  and  all  manipulations  should  be  executed  by 
means  of  instruments.  There  are,  however,  conditions  under  which 
it  is  not  only  permissible,  but  advisable,  to  execute  certain  portions 
of  the  operative  technic  with  the  hand,  such  as  the  delivery  of  tumors, 
the  separation  of  adhesions,  visualizing  certain  organs,  etc.  In  these 
instances  the  manipulations  should  be  accomplished  through  ample 
wounds  of  approach,  and  with  as  much  gentleness  as  is  consistent 
with  the  desired  end. 

The  danger  of  contamination  from  the  air  is  not  at  any  time  a  great 
one;  it  may  be  obviated  by  refraining  from  cleansing  the  operating 
room  immediatel}^  before  an  operation,  and  by  avoiding  unnecessary 
walking  about  on  the  part  of  the  operator  and  his  assistants,  which 
would  tend  to  agitate  infective  material  resting  upon  the  floor.  Con- 
tamination from  the  exhalations  of  those  present  in  the  operating 
room,  especially  those  afflicted  with  inflammatory  processes  of  the  air 
passages,  may  be  prevented  by  the  use  of  suitable  gauze  masks.  Sneez- 
ing, coughing,  or  laughing  immediately  contiguous  to  the  operative 
field  should  be  avoided.     The  issuing  of  orders  to  the  assistants  should 


THE  ASEPTIC  OPERATION  125 

be  restricted  to  the  operator,  whose  face  should  be  turned  aside  when 
speaking,  especially  if  the  face  mask  be  dispensed  with  while  he  is 
delivering  clinical  lectures. 

Dressings  are  applied  to  the  wound  to  absorb  discharges,  to  prevent 
the  entrance  of  infective  substances,  and  to  immobilize  the  part.  The 
wound  should  be  covered  with  sterile  gauze,  the  thickness  of  which  is 
proportionate  to  the  extent  of  trauma  inflicted,  and  the  amount  of 
secretion  to  be  absorbed.  This  is  covered  with  a  liberal  layer  of 
cotton  which  acts  as  a  pad  and  mechanically  prevents  bacteria  from 
gaining  access  to  the  wound.  The  dressing  is  held  in  place  by  a  firmly 
applied  bandage,  which  may  consist  of  gauze,  muslin,  starch,  or  gyp- 
sum according  to  the  extent  of  immobilization  desired.  The  use  of 
adhesive  plaster  for  the  purpose  of  holding  dressings  in  place  will,  at 
times,  be  found  exceedingly  convenient. 


CHAPTER  XII 

GENERAL  AND   LOCAL  ANESTHESIA 
By  Henry  C.  Falk,  M.  D. 

GENERAL  CONSIDERATIONS 

Abolition  of  the  sense  of  pain  is  called  analgesia. 

Anesthesia  is  a  term  employed  to  designate  loss  of  sensory  conduc- 
tion, i.  e.,  pain,  touch,  temperature,  etc.  When  anesthesia  and  uncon- 
sciousness coexist  as  the  outcome  of  the  introduction  into  the  body 
of  an  agent  administered  for  the  purpose,  the  condition  is  known  as 
narcosis.  The  term  "narcosis"  is,  however,  used  to  designate  uncon- 
sciousness, the  result  of  other  conditions,  and  for  this  reason  surgical 
anesthesia  and  unconsciousness  is  called  general  anesthesia. 

General  anesthetics  may  be  introduced  into  the  body:  (1)  By 
inhalation  through  the  respiratory^  tract;  (2)  by  absorption  through 
the  mucous  membrane  of  the  rectum;  (3)  by  introduction  directly 
into  the  circulation  (injection  into  a  blood  vessel). 

The  anesthetic  agents  most  commonly  employed  are  ether,  chloro- 
form, nitrous  oxid,  and  ethyl  chlorid. 

LOCAL  ANESTHESIA 

Local  anesthesia,  or  analgesia,  results  from  direct  paralysis  in  certain 
areas  of  the  terminal  sensory  nerve  filaments,  or  abolishes  the  con- 
ductivity of  the  nerve  trunk  leading  to  them. 

Local  anesthesia  may  be  produced  by : 

(1)  Freezing. 

(2)  Surface  application. 

(3)  Infiltration  anesthesia. 

(4)  Paraneural  anasthesia. 

(5)  Intraneural  anesthesia. 

(6)  Intravenous  anesthesia. 

(7)  Spinal  anesthesia. 

For  this  purpose  (except  in  the  first  instance)  cocain  or  one  of  its 
derivatives  is  usually  used.     Spinal  anesthesia  may  be  produced  by 

126 


GENERAL  AND  LOCAL  ANESTHESIA 


127 


agents  other  than  eoeain  and  its  derivatives ;   these,  however,  will  be 
taken  up  later  (p.  141). 

GENERAL  ANESTHESIA 

Though  the  names  of  Warren  (Boston,  1805),  Long  (Georgia, 
1815),  Hickman  (England,  1820),  Stockman  (Utica,  1821),  Geradin 
(Paris,  1828),  Ives  (New  Haven,  1833),  and  Colton  (Boston,  1844), 
are  associated  with  the  early  efforts  to  abolish  pain  from  surgery,  it 
was  left  to  William  T.  G.  Morton  of  Boston  (1848)  firmly  to  establish 
the  practical  utility  of  surgical  anesthesia  by  the  administration  of 
"sulphuric  ether"  by  inhalation,  the  effect  of  which  may  be  best 
expressed  by  quoting  the  epitaph  on  his  tombstone : 

"William  T,  G.  Morton,  Inventor  and  Revealer  of  Anesthetic 
Inhalation;  before  whom,  in  all  times,  surgery  was  agony;  since 
whom,  science  has  control  of  pain." 

Action  of  Inhalation  Anesthesia. —  Exact  knowledge  of  the  chemical 
or  cellular  changes  which  take  place  as  the  result  of  the  administra- 
tion of  anesthetics  is  not  available.  Most  present  day  theories  of  their 
modus  operandi  are  based  upon  the  assumption  that  a  chemical  or 
physicochemical  union  between  the  anesthetic  agent  and  the  lecithin- 
cholesterin  bodies  of  the  cell  takes  place  (Bernard  and  Dubois;  Lip- 
oids, Meyer-Overt  on).  For  the  study  of  extended  discussion  in  this 
connection,  the  reader  is  referred  to  special  works  on  General  Anes- 
thesia. 

General  Centra-Indications. —  Induction  of  general  anesthesia  is 
contra-indicated  in  uncompensated  heart  disease,  in  myocarditis,  in 
advanced  arteriosclerosis,  and  during  severe  shock.  In  certain  of 
these  cases,  local  or  spinal  anesthesia  may  be  employed. 

Mortality 


AMERICAN   STATISTICS 

DEATHS 

CASES 

1.  Nitrous  oxid  with  oxygen 

2.  Ether  drop  or  vapor 

? 

1 

0 

14,878 

5,623 

2,048 

905 

3.     Chloroform  drop  or  vapor 

4.     Ethyl  chlorid  

Preparation   of   Patients   for   General   Anesthesia. —  When    feasible, 
patients  should  be  placed  in  bed  forty-eight  hours  before  the  time  of 


128  WOUNDS 

operation,  with  the  view  of  interpreting  the  cardiovascular  condition, 
eliminative  functions,  and  other  manifestations  bearing  on  the  char- 
acter, the  method,  and  the  agent  to  be  selected  for  narcosis.  The 
bearing  that  this  has  on  the  selection  of  the  agent  to  be  used  is  taken 
up  in  the  discussion  of  each  anesthetic. 

In  a  general  way,  it  may  be  said  that  a  light  diet,  large  quantities  of 
water,  and  absence  of  all  ingesta  for  seven  hours  before  narcosis  is 
desirable.  Preliminary  thorough  cleansing  of  the  mouth,  especially 
the  teeth,  tends  to  obviate  the  occurrence  of  post  operative  complica- 
tions in  the  respiratory  tract.  In  emergency  cases,  the  stomach  may 
be  lavaged  before  anesthesia  is  produced. 

The  narcotist  should  be  prepared  to  meet  complications  likely  to 
occur,  and  provision  should  be  made  to  meet  promptly  the  special 
indications  in  a  given  instance.  The  delay  consequent  to  neglect  in 
this  connection  may  determine  the  outcome  of  the  operative  procedure. 

Ether  Anesthesia  —  Contra-Indications. —  The  administration  of  ether 
is  contra-indicated  in  cases  of  nephritis,  chronic  bronchitis,  emphy- 
sema, lung  tuberculosis,  aneurism,  and  in  advanced  arterial  disease, 
especially  when  the  latter  is  accompanied  by  high  blood  pressure; 
however,  the  harmful  effects  of  ether  are  considerably  lessened  when 
it  is  carefully  administered  together  with  other  agents. 

Stages  op  Ether  Anesthesia. —  First  Stage. —  Respiration  irregu- 
lar, blood  pressure  increased,  pulse  bounding,  skin  flushed,  salivary 
secretion  increased ;  spasm  of  the  glottis  and  violent  struggling  attends 
the  concentrated  administration  of  ether  in  this  stage.  Anesthesia 
unreliable. 

Second  Stage. —  Respiration  still  irregular,  pulse  full  but  slower, 
salivation  continues,  spasm  of  the  muscle  of  the  jaw,  violent  strug- 
gling, coughing,  and  vomiting  attend  this  stage.  The  pupils  gradually 
dilate  but  react  to  light.     Anesthesia  still  unreliable. 

Third  Stage. —  Respiration  regular  and  deep,  pulse  full  and  regular, 
skin  flushed,  salivation  ceases.  Pupils  normal  in  size  and  react  to 
light.  During  this  stage  the  secretions  are  arrested ;  if  tears  suffuse 
the  eyes  or  perspiration  appears  upon  the  forehead,  complete  narcosis 
is  no  longer  maintained.  The  occurrence  of  irregularity  of  respira- 
tion, and  return  of  the  eyelid  reflex  are  additional  signs  in  this  con- 
nection. However,  there  is  no  one  invariable  indication  of  returning 
consciousness,  the  several  signs  must  be  interpreted  in  conjunction 
with  the  others. 

Fourth  Stage. —  Overdose :     respiration  becomes   soft,   shallow   or 


GENERAL  AND  LOCAL  ANESTHESIA 


129 


sighing;   tlie  pulse  irregular  and  small;   the  skin  cyanosed,  cold,  and 
clammy;  the  pupils  are  widely  dilated  and  do  not  react  to  light. 

Ether  narcosis  is  preceded  by  nitrous  oxid,  chloroform,  or  ethyl 
chlorid  with  the  view  of  eliminating,  or  at  least  lessening,  the  objec- 
tionable features  in  the  first  two  stages.  Unless  contra-indicated,  the 
narcosis  may  be  preceded  by  the  h3'podermic  administration  of  1/6  of 
a  grain  of  morphia  and  1/150  of  a  grain  of  atropin,  one  hour  before 
the  beginning  of  the  anesthesia,  a  measure  which  lessens  the  patient 's 
apprehension  and  renders  easier  the  production  of  complete  narcosis. 

When  ether  alone  is  used,  the  open  or  drop  method  may  be  regarded 
as  the  safest  means  of  producing  narcosis,  though  the  objectionable 
features,  such  as  coughing,  struggling,  gagging  and  vomiting,  together 
with  the  difficulty  of  controlling  the  dosage,  render  it  less  desirable 
than  are  other  methods  of  administration. 

The  Mayo  broth- 
ers report  the  em- 
ployment of  the 
open  drop  method 
in  more  than  14,- 
000  administra- 
tions without  acci- 
dent. However, 
this  does  not  mean 
that  avoidance  of 
the  objectionable 
features  stated 
need  not  be  given 
due  consideration. 

In  the  open  metJiod  of  administration  the  ordinary  v.  Esmarch 
chloroform  mask,  or  one  of  its  numerous  modifications  (Fig.  82),  is 
employed.  The  ether  is  slowly  dropped  on  the  gauze  mesh  at  a  rate 
proportionate  to  the  indications. 

"Where  the  services  of  special  anesthetists  are  available,  the  open  or 
drop  method  of  administration  is  rarely  used.  It  ma}^  be  true  that 
the  seeming!}^  complicated  apparatus  employed  by  special  anesthetists 
find  justification  for  use  mainl}-  because  of  the  comfort  to  the  patient, 
the  ease  with  which  the  narcotic  state  is  attained  and  maintained,  the 
marked  decrease  in  amount  of  ether  used,  and  the  evenness  of  the 
narcosis. 

The  closed  method  of  administering  ether  was  developed  in  England 


Fig.  82. —  Yaxkauer-Gwatiimey  Drop  axd  Vapor 
Mask  (GAvathmey). 


130 


WOUNDS 


by  Clover  (1872)  who  employed  an  api)aratus  similar  to  the  one  now 

used  for  the  nitrous  oxid  ether  sequence. 

Thomas  Bonnet  of  New  York  devised  an  apparatus  which,  though 

modified  by  various  anesthetists  as  regards  minor  details,  may  be 

considered  standard  in  this  connection.     A  satisfactory  notion  of  the 

mechanism  may   be   gathered   from   the    accompanying    illustration 

(Fig.  83). 
The  employment  of  the  nitrous   oxid   ether  sequence   avoids   the 

so-called  first  and  second  stages  of  ether  narcosis  with  their  mental 

and  physical  irrita- 
tion, coughing, 
strangulation  and 
cyanosis,  and  per- 
mits of  complete, 
surgical  anesthesia 
in  about  three  min- 
utes. The  technic 
of  the  method  is 
simple.  The  mask 
is  placed  on  the 
face  of  the  patient, 
who  is  caused  to  in- 
hale nitrous  oxid 
until  unconscious- 
ness is  produced, 
when  the  ether  va- 
por is  allowed  slow- 
ly to  impregnate 
the  tidal  mixture. 
If  the  patient  shows 
the  least  evidence  of 
respiratory  irrita- 
tion, the  supply  of 
ether  is  discontinued 
aud  nitrous  oxid 
alone  is  given,  until 
the  signs  of  irrita- 
tion have  disappeared  when  the  ether  is  again  gradually  given.  When 
complete  ether  narcosis  is  established,  the  patient  rebreathes  the 
warmed  ether  vapor  which  he  has  expired  into  the  rubber  bag.     The 


Fig.  8.3.—  Gwatiimey  Nitrous  Oxid  Ether  Apparatus 
(Gwathmey). 


GENERAL  AND  LOCAL  ANESTHESIA 


131 


ether  iu  the  etlier  chamber  is  replenished  every  three  to  five  minutes. 
If  slight  cyanosis  occurs  the  patient  is  allowed  to  breathe  air  for  a  few 
moments.  Deep  anesthesia  is  easily  and  safely  maintained  by  this 
means.  When  in  prolonged  operations  a  tendency  to  cyanosis  develops, 
the  occasional  administration  of  small  amounts  of  oxygen,  or  a  few 
breaths  of  air,  restores  the  patient's  natural  color. 

The  vapor  method  of  anesthesia  consists  of  passing  air,  oxygenated 
air,  or  other  gases  either  over  or  through  the  anesthetic  agent  which 
is  thus  vaporized  before  entering  the  respiratory  tract  of  the  patient. 
When,  the  vapor  is  carried  directly  into  the  pharynx  or  trachea,  endo- 


FiG.  84. —  Three  Bottle  Vapor  Apparatus  Connected  with  Electric  IIeatkk 
AND  Vapor  Mask  (Gwathmey). 

pharyngeal  or  intratracheal  insufflation  apparatus  is  used.  When 
the  vapor  is  passed  through  warmed  w-ater  the  term  "warmed  vapor 
method  ' '  is  used.  The  apparatus  employed  for  vaporizing  and  warm- 
ing anesthetic  agents  is  shown  in  Fig.  84.  In  suitable  cases  the  three 
bottle  portion  of  the  apparatus  may  be  connected  with  hand  or  foot 
bellows  or  w^ith  an  electric  pump,  and  the  face  mask  may  be  replaced 
by  nasal  tubes,  perforated  mouth  gag,  pharjTiigeal  or  intratracheal 
tubes. 

While  satisfactory  anesthesia  may  be  produced  by  the  open  or  drop 
method,  the  use  of  warmed  and  vaporized  anesthetics  may  be  regarded 
as  markedly  lessening  the  objectionable  features  of  the  former  method. 


132  WOUNDS 

An  apparatus  which  permits  of  the  addition  of  oxygen  to  the  vaporized 
anesthetic  is  desirable. 

Chloroform  Anesthesia. —  Chloroform,  announced  to  the  French 
Academy  in  1847  (Flourens),  came  into  general  use  as  the  outcome 
of  a  presentation  by  Sir  L.  W.  Simpson  in  the  latter  part  of  the  same 
year. 

The  use  of  chloroform  is  contra-indicated  in  status  lymphaticus,  in 
the  presence  of  low  blood  pressure,  in  prolonged  operations,  and  in 
those  in  which  the  patient  is  placed  in  a  sitting  posture. 

The  use  of  chloroform  is  indicated  particularly  in  obstetrical  cases 
where  the  heart  is  usually  somewhat  hypertrophied.  It  should  also 
be  used  for  persons  of  advanced  age,  and  in  cardionephritic  cases. 

Chloroform  Narcosis. —  Chloroform  is  a  powerful  protoplasmic 
poison  which  causes  death  by  depressing  the  circulation.  Its  admin- 
istration is  attended  by  the  same  four  stages  of  anesthesia  that  occur 
when  ether  is  used ;  however,  the  first,  second,  and  third  stages  merge 
into  each  other  so  rapidly  that  they  cannot  always  be  distinguished, 
which  of  course  makes  the  establishment  of  the  fourth  stage  (overdose) 
readily  attainable.  In  many  instances,  however,  death  from  chloro- 
form has  occurred  during  the  early  stages  of  administration. 

Chloroform  is  always  administered  mixed  with  air  or  oxygen. 
Complete  surgical  anesthesia  may  be  produced  by  slowly  dropping 
chloroform  on  a  handkerchief,  napkin,  gauze,  etc.,  held  in  close 
proximity  to  the  nose  and  mouth. 

The  practice  of  this  method  of  administration  presents  no  technical 
difficulties,  is  largely  indulged  in,  and  is,  perhaps,  justifiable  in  cases 
of  emergency;  however,  the  difficulty  of  standardi'zing  the  dose,  and 
the  fact  of  the  objectionable  features  attendant  upon  the  inhalation 
of  the  agent  in  this  manner,  which  are  overcome  by  the  use  of  properly 
devised  apparatus,  should  argue  for  the  abandonment  of  the  older 
method. 

The  Roth-Drdger  apparatus,  designed  to  supply  chloroform  vapor 
in  an  atmosphere  of  oxygen,  may  be  regarded  as  the  safest  method  of 
administering  the  agent.  The  face  piece  admits  of  the  admixture  of 
air,  diluting  the  chloroform  oxygen  mixture  into  a  readily  respirable 
vapor.  The  apparatus  has  been  modified  so  as  to  permit  the  use 
of  any  desired  combination  of  ether,  chloroform,  oxygen  or  air,  or  of 
any  one  of  these  alone  (Fig.  85). 

Chloroform  may  be  administered  satisfactorily  by  means  of  the 
Yankauer-Gwathmey  drop  and  vapor  mask  (Fig.  82). 
The  prolonged  contest  between  the  followers  of  chloroform  and 


GENERAL  AND  LOCAL  ANESTHESIA 


133 


ether,  as  to  the  relative  safety  of  the  two  agents  and  their  derivatives, 
may  be  regarded  as  ended.  Ether  is  the  safer  of  the  two,  though 
they  each  have  special  indications  for  their  use.  It  is,  however,  proper 
to  add  that  modern  methods  of  administration  would  seem  to  have 
greatly  lessened  the  number  of  special  indications  for  the  use  of 
chloroform  as  an  anesthetic  when  expert  services  are  available. 

Nitrous  Oxid. —  Nitrous  oxid  was  discovered  by  Priestly  in  1772. 
Its  use  as  an  anesthetic  was  first  publicly  demonstrated  by  Colton, 
who  administered  it  to  Wells  and  painlessly  extracted  a  tooth,  in  1844, 
at  Hartford,  Conn.  Wells  used  it  until  his  death  (1848)  for  extract- 
ing teeth  painlessly.     In  1867  Colton  reported  20,000  successful  cases. 

At  hep  Chloroform 


DRAGERWERK 
LUBECK 


Fig.  85. —  The  Eotii-Drager  Apparatus  : 
Hand  Double  Apparatus  (Gwathmey). 

The  use  of  nitrous  oxid  is  indicated  most  largely  for  operations 
occupying  a  short  period  of  time,  such  as  extraction  of  a  tooth,  avul- 
sion of  a  toe  nail,  opening  of  an  abscess,  etc.  Nitrous  oxid  in  com- 
bination with  oxygen  produces  profound  anesthesia  which  may  be 
sufficiently  prolonged  to  make  possible  the  execution  of  major  surgical 
work.  However,  the  muscular  rigidity  which  accompanies  nitrous- 
oxid-oxygen  anesthesia  restricts  considerably  its  practical  field  of 
usefulness.  Nitrous  oxid  anesthesia  may  be  employed  safely  for  brief 
operations,  and,  when  combined  with  oxygen  and  used  by  an  expert, 


134  WOUNDS 

may  be  properly  used  in  operations  where  the  administration  of  any 
other  anesthetic  is  undesirable.  Its  greatest  field  of  usefulness  is 
when  administered  preliminary  to  ether,  obviating  as  it  does  the 
objectionable  features  of  the  latter  when  given  alone. 

Nitrous  Oxid  Narcosis. —  Nitrous  oxid  may  be  administered  with 
the  patient  seated.  As  the  state  of  unconsciousness  is  rapidly  pro- 
duced, care  should  be  taken  that  the  apparatus  used  is  in  good  work- 
ing order.  The  patient  is  caused  to  breathe  deeply  (eight  or  ten 
times)  of  the  pure  gas  before  adjusting  the  valves  for  rebreathing. 
The  narcotic  state  may  be  divided  into  three  stages,  but  these  are  not 
clearly  differentiated  because  of  the  rapidity  with  which  the  agent 
acts.  The  complete  anesthetic  state  is  accompanied  by  deep  stertorous 
breathing,  marked  cyanosis,  clonic  muscular  contraction  (jactitation), 
the  pupils  are  dilated,  the  eyes  rotated  or  fixed ;  the  pulse  is  full  and 
bounding.  Full  anesthesia  lasts  for  about  one  minute  after  the  mask 
is  removed ;  this  may  be  somewhat  prolonged  if  the  patient  is  allowed 
to  inhale  air  to  the  extent  of  one  inspiration  to  five  of  the  gas.  The 
after  effects  of  nitrous  oxid  anesthesia  are  exceedingly  slight,  though 
occasionally  headache  and  vomiting  follow. 

Nitrous  Oxid  Analgesia. —  A  peculiar  state  of  general  analgesia 
ma}^  be  produced  by  the  inhalation  of  nitrous  oxid.  The  method  is 
used  by  surgeons  when  executing  painful  dressings  of  wounds,  removal 
of  deep  drainage,  etc.  It  consists  of  placing  over  the  patient's  nose 
(the  mouth  being  left  free)  an  apparatus  connected  with  the  nitrous 
oxid  container.  The  patient  is  instructed  to  inhale  the  gas  through 
the  nose  when  pain  occurs.  In  this  way  a  state  of  analgesia  is  pro- 
duced, though  the  patient  does  not  lose  consciousness. 

Ethyl  Chlorid. —  The  anesthetic  qualities  of  ethyl  chlorid  were  dis- 
covered b}'  Flourens  (1847).  It  was  used  in  a  minor  surgical  case  by 
Heyfelder  in  1848,  but  did  not  come  into  general  use  until  1895, 

Ethyl  chlorid  may  be  used  when  anesthesia  need  not  last  longer  than 
from  two  to  four  minutes.  Its  toxic  effects  increase  in  proportion  to 
the  length  of  time  it  is  used.  Being  extremely  volatile  the  dosage  is 
difficult  to  control  and  alarming  symptoms  occur  with  great  rapidity. 
It  may  be  used  for  operations  occupying  a  short  period  of  time, 
though  it  may  not  be  regarded  as  useful  for  the  purpose  as  nitrous 
oxid. 

Preliminary  to  the  administration  of  ether  by  the  open  method,  a 
few  drops  of  ethyl  chlorid  will  obviate  the  excitement,  irritation,  etc., 
attendant  upon  the  use  of  ether  in  this  way. 


GENERAL  AND  LOCAL  ANESTHESIA 


135 


The  signs  of  overdose  are  similar  to  those  of  ether  poisoning. 

Intratracheal  Anesthesia.—  The  complicated  problem  presented  by 
intratracheal  anesthesia  was  considerably  simplified  by  Meltzer 
(1909)  whose  apparatus  is  shown  in  Fig.  86.  Elsberg  and  Janeway 
have  also  devised  apparatus  for  intratracheal  insufflation  of  ether 
which  are  more  elaborate  than  Meltzer 's. 

The  essentials  of  the  machine  are  a  pump  to  force  air  into  the  lungs 
under  pressure ;  a  mercury  manometer  fitted  with  a  safety  valve  which 
does  not  allow  the  pressure  to  exceed  20  mm.  Hg. ;  a  container  for 
the  ether  through  which  air  passes,  and  a  chamber  in  which  the  ether- 
ized air  is  warmed  before  entering  the  lungs ;  a  tube  of  less  than  one 


Fig.   86. —  ^Meltzer's   Sijiple  App.vratus  fot  Tracheal  Isufflation 

(Gwathmey). 


third  the  diameter  of  the  trachea  to  carry  the  ether  air  into  the  trachea 
and  allow  the  escape  of  ether  and  expired  air;  and  an  interrupter 
which  arrests  the  flow  of  etherized  air  from  five  to  eight  times  a 
minute,  thus  permitting  the  escape  of  carbon  dioxid  from  the  alveoli 
of.  the  lungs. 

Intratracheal  anesthesia  is  especially  indicated  for  the  purpose  of 
maintaining  intra-alveolar  pressure  and  preventing  the  collapse  of 
the  lung  when  the  thoracic  cavity  is  invaded;  to  keep  the  anesthetist 
away  from  the  field  when  the  head  or  neck  is  to  be  operated  upon ; 
in  operations  involving  the  upper  air  passages,  where  there  is  danger 


136  WOUNDS 

of  aspirating  septic  material  or  blood  iuto  the  lungs ;  and  in  cases  of 
intestinal  obstruction  with  fecal  vomiting. 

The  narcotic  state  is  first  produced  in  the  usual  manner  followed 
by  the  introduction  of  the  intratracheal  tube,  a  step  accomplished  at 
limes  with  considerable  difficulty.  The  difficulties  of  the  technical 
problem,  together  with  the  trauma  to  the  air  passages,  attendant  upon 
*he  introduction  of  the  tracheal  tube,  and  the  objections  to  spraying  a 
protoplasmic  poison  directly  into  the  lungs,  would  seem  to  justify  the 
warning  that  intratracheal  insufflation  of  anesthetics  should  be 
employed  only  when  the  affliction  of  the  patient  is  sufficiently  men- 
acing to  warrant  exposure  to  the  additional  risks  involved  in  its 
employment. 

Colonic  Anesthesia. —  Pirogoff  in  1847  published  his  work  on  ether- 
ization in  which  anesthesia  by  the  absorption  of  ether  through  the 
rectal  mucosa  was  described ;  he  reported  eighty-one  cases  with  two 
deaths.  The  method  was  revived  in  1884  by  Molliere,  but  again  fell 
into  disuse  owing  to  the  diarrhea  and  bloody  stools  which  followed  the 
use  of  ether  vapor,  or  of  liquid  ether  in  the  rectum.  Cunningham  and 
Sutton  again  revived  it  in  1910,  using  a  warmed  ether  vapor  pumped 
into  the  colon,  with  moderate  success.  In  1913  Gwathmey  used  a 
mixture  of  oil  and  ether,  injecting  it  into  the  rectum ;  this  seemed  to 
possess  certain  advantages  over  the  other  methods  of  rectal  anesthesia. 

Contra-Indications  : 

1.  General  conditions  that  also  contra-indicate  inhalation  of  ether. 

2.  In  the  presence  of  pathological  conditions  in  the  lower  bowel. 

3.  Operations  on  the  lower  bowel,  especially  when  the  actual 
cautery  is  used. 

4.  When  the  introduction  of  the  mixture  is  attended  with  pain. 

5.  In  abdominal  operations,  because  of  the  distention  of  the  gut 
with  gas. 

Special  Indications  : 

1.  In  exophthalmic  goiter  as  a  part  of  anoci-association  (Crile). 

2.  In  bronchoscopy,  gastroscopy,  and  certain  operations  about  the 
head  and  neck. 

3.  When  obesity  is  extreme,  associated  with  respiratory  difficulty. 
The  preliminary  preparation  and  technic  of  the  procedure  accord- 
ing to  Gwathmey,  is  as  follows : 

*'The  night  hefore  the  operation  castor  oil  is  administered  followed 
in  the  morning  by  a  colonic  irrigation  until  the  return  is  clear ;   how 


GENERAL  AND  LOCAL  ANESTHESIA       137 

ever,  the  bowel  is  rested  for  three  hours  before  the  operation ;  one 
hour  before  the  operation  five  to  twenty  grains  of  chloretone  dissolved 
in  four  drams  of  ether,  mixed  with  four  drams  of  olive  oil  are  intro- 
duced into  the  rectum  with  the  patient  in  Sims'  position.  14  grain, 
of  morphin  with  1/150  of  atropin  is  given  hypodermatically.  The 
dosage  is  regulated  according  to  the  age  of  the  patient.  Thirty  min- 
utes before  the  operation  the  oil  mixture  is  introduced  slowly  into  the 
rectum,  through  a  small  rectal  tube.  To  every  two  to  three  ounces  of 
ether,  one  ounce  of  oil  is  added.  One  ounce  of  ether  to  twenty  pounds 
of  body  weight  may  be  used;  however,  the  total  quantity  of  oil-ether 
mixture  should  not  exceed  eight  ounces. ' ' 

The  patient  shows  signs  of  anesthesia  in  from  five  to  forty  minutes 
after  the  introduction  of  the  oil-ether  mixture  into  the  rectum.  The 
stages  of  anesthesia  are  the  same  as  when  the  agent  is  administered 
by  inhalation.  When  narcosis  is  complete  the  patient  is  apparently 
in  a  natural  sleep,  the  lid  reflexes  being  still  present. 

The  signs  of  overdose  are  loss  of  lid  reflex,  slight  cyanosis,  and 
stertorous  breathing.  When  signs  of  overdose  appear,  all  available 
ether  mixture  is  immediately  withdrawn  from  the  rectum,  a  task  at 
times  accomplished  with  considerable  difficult}^ ;  beyond  this  the  usual 
means  of  resuscitation  are  to  be  employed.  The  fact  that  evidence  of 
poisoning  cannot  be  followed  by  sutficiently  prompt  withdrawal  of  the 
mixture  to  obviate  with  any  reasonable  degree  of  certainty  the  occur- 
rence of  unfortunate  results  has  prevented  the  method  from  being 
widely  accepted. 

The  assumption  that  in  some  instances  the  patient  may  be  so  appre- 
hensive of  operative  procedure  as  to  justify  the  introduction  of  an 
anesthetic  without  his  knowledge,  as  is  proposed  in  cases  of  exophthal- 
mic goiter,  would  seem  to  be  a  flimsy  basis  upon  which  to  justify 
taking  the  additional  risks  attendant  upon  the  use  of  colonic 
anesthesia. 

Intravenous  Anesthesia. —  This  method  of  anesthesia,  recently  pro-; 
posed,  docs  not  seem  to  possess  any  advantages  that  counterbalance' 
the  dangers  of  the  introduction  of  an  uncontrolled  poison  into  the' 
circulation;  indeed,  the  method  is  mentioned  here  only  to  condemn  it. 

LOCAL  ANALGESIA 

The  application  of  cold  to  the  skin  will  produce  analgesia,  which, 
though  unreliable,  may  suffice  for  simple  incision  of  the  skin,  such  as 


138 


WOUNDS 


the  opening  of  an  abscess,  etc.  Return  of  sensation  is  accompanied 
by  considerable  pain.  In  instances  where  nutrition  of  the  skin  is 
alread}^  impaired  (carbuncle),  the  trophic  disturbance  consequent  to 
freezing  is  objectionable. 

For  the  purpose  ice  may  be  used,  though  the  intent  is  best  accom- 
plished by  spraying  the  area  with  ether  or  ethyl  chlorid ;  of  the  two, 
the  latter  is  the  more  desirable.  Ethyl  chlorid  is  obtainable  in  the 
market  in  a  glass  tube  which  has  a  capillary  opening  fitted  with  a 
valve  (Fig.  87).  The  container  is  held  about  eight 
inches  away  and  the  preparation  sprayed  on  the 
skin  until  numbness  and  loss  of  sensation  occur. 

Surface  Application. —  Mucous  membranes  and  the 
deeper  tissues  may  be  anesthetized  by  cocain  and  its 
derivatives.  Cotton  saturated  with  a  five  to  ten  per 
cent  solution  of  cocain  is  applied,  and  at  the  end  of 
from  five  to  ten  minutes  analgesia  is  produced.  This 
method  is  chiefly  used  preliminary  to  operations 
upon  the  eye,  nose,  throat,  urethra,  and  rectum. 
"When  employed  in  cavities  the  toxic  symptoms  in- 
dicating absorption  of  the  drug  must  be  taken  into 
account.  Secondary  hemorrhage  sometimes  follows 
when  the  agent  is  used  in  this  manner. 

Infiltration  Analgesia. —  Local  analgesia  is  most 
frequently  produced  by  the  infiltration  method. 
For  this  purpose  cocain  has  been  largely  used ;  its 
toxicity  (more  than  1.5  grains  should  never  be  in- 
jected) and  the  fact  that  it  cannot  be  sterilized  by 
boiling  has  caused  it  to  be  replaced  by  novocain,  eu- 
cain,  tropacocain,  and  alypin. 

Novocain  is  the  agent  most  frequently  employed. 
It  may  be  used  in  weak  solutions  (1  per  cent)  combined  with  adrena- 
lin (m.  ii  of  a  1 :1,000  solution  of  adrenalin  to  dram  i  of  the  novocain 
solution). 

A  5  c.  cm.  syringe,  armed  with  a  1  to  IV2  inch  twenty  gauge  needle, 
is  filled  with  the  solution.  The  skin  of  the  area  to  be  rendered 
analgesic  is  ''pinched  up"  between  the  thumb  and  forefinger  of  one 
hand  and  the  needle  is  entered  to  just  beneath  the  epidermis.  The 
first  injection  should  be  made  intradermal,  not  subcutaneous.  When 
the  infiltration  is  properly  made  a  distinct  blanched  wheal  appears 


Fig.  87. —  Ethyl 
Chlorid  Contain- 
EE  (Gwathmey). 


GENERAL  AND  LOCAL  ANESTHESIA 


139 


at  the  site  of  the  infiltration  (Fig.  88).  The  needle  is  now  advanced 
and  a  second  wheal  caused  to  develop  immediately  contiguous  to  the 
first.  This  maneuver  is  repeated  until  a  linear  area  of  infiltrated 
skin  is  created  extending  slightly  beyond  the  extent  of  the  superficial 
incision.  After  the  skin  is  rendered  analgesic  the  deeper  tissues  may 
be  infiltrated  in  a  similar  manner,  though  in  this  situation  solutions  as 
weak  as  1/4  P^i"  cent  may  be  employed.  The  blanching  of  the  deeper 
tissues  consequent  to  their  infiltration  at  times  renders  their  identifi- 
cation difficult. 


Fig.  88. —  Infiltration  Anesthesia. 


Extensive  operations,  including  celiotomy,  major  amputations,  and 
removal  of  neoplasms  of  considerable  size  may  be  painlessly  performed 
in  this  way.  The  operative  procedure  is,  however,  not  a  little  pro- 
longed by  employment  of  the  measure.  The  fears  of  the  patient,  the 
tension  under  which  the  surgeon  and  his  assistants  work,  and  the  fact 
that  complete  anesthesia  may  not  be  assured  would  seem  to  make  it 
necessary'-  for  special  indications  to  be  presented  before  using  this 
method  of  analgesia. 

Paraneural  Analgesia. —  The  injection  of  an  analgesic  solution  into 


<140 


WOUNDS 


the  tissues  immediately  contiguous  to  a  sensory  nerve  trunk  will 
produce  anesthesia  of  the  area  supplied  by  that  nerve.  The  action 
of  the  measure  is  explained  on  the  ground  that  the  agent  employed  is 
diffused  through  the  tissues  surrounding  the  point  of  injection,  includ- 
ing the  nerve  trunk.  This  method  of  analgesia  acts  with  certainty 
when  applied  to  fingers  and  toes  and  will  be  found  to  render  painless 
the  opening  of  infective  processes,  and  the  amputation  of  distal 
phalanges,  the  removal  of  ingrowing  toe  nails,  etc.  The  injection 
should  be  made  in  a  portion  of  the  part  that  is  not  infected. 


Fig.  89. —  Paraneural  Anesthesia. 

The  arrows  indicate  the  direction  in  ■\vhich  the  needle  is 
introduced. 


The  skin  surrounding  the  base  of  the  finger  or  toe  is  painted  with 
full  strength  iodin.  At  a  point  a  little  above  the  w^eb  of  the  digit  at 
its  posterior  lateral  aspect,  the  injection  is  made  with  a  fine  needle 
and  a  wheal  is  produced  through  which  the  needle  is  plunged  deeply 
into  the  part  as  indicated  in  the  illustration  (Fig.  89).  This  pro- 
cedure is  repeated  in  the  posterior  medial  aspect  of  the  base  of  the 
digit.  With  the  forward  injection  2  c.  cm.  of  5  per  cent  novocain  solu- 
tion is  used  and  with  the  backward  thrust  1  c.  cm.    A  constrictor  is  then 


GENERAL  AND  LOCAL  ANESTHESIA       141 

applied  at  the  base  of  the  finger,  a  measure  which  intensifies  and 
prolongs  the  analgesia. 

Intraneural  Analgesia. —  Direct  nerve  infiltration  is  more  certain  in 
its  effect  and  a  much  smaller  quantity  of  the  solution  is  required  than 
in  either  the  infiltration  or  paraneural  methods.  It  may  be  used  in 
the  trunks  of  large  nerves,  especially  those  readily  accessible,  such  as 
the  ulnar,  median,  musculospinal  at  the  elbow,  etc.,  though  the  more 
deeply  located  nerves  may  be  infiltrated  when  exposed  during  the 
operative  procedure.  The  special  areas  rendered  analgesic  by  infil- 
tration of  a  given  nerve  are  determined  as  the  outcome  of  a  close  study 
of  its  anatomical  distribution. 

A  nerve  may  be  infiltrated  at  a  distance  from  the  site  of  operation 
or  after  exposure  within  the  field  of  operation.  If  the  former  method 
be  chosen,  the  incision  exposing  the  nerve  should  not  be  closed  until 
the  operation  is  fijiished,  as  repeated  injections  may  be  necessary. 
The  exposed  nerve  should  not  be  manipulated  with  forceps,  etc.  The 
solution  of  novocain  (5  per  cent)  is  slowly  propelled  through  a  fine 
needle  carefully  introduced  into  the  nerve  tissue,  producing  a  slight 
fusiform  swelling  at  that  point.  No  more  than  ten  or  fifteen  minims 
of  the  solution  may  be  used  safely  in  this  way.  Complete  anesthesia 
results  in  from  five  to  fifteen  minutes. 

Intravenous  Analgesia. —  This  method  is  applicable  only  to  the 
extremities.  The  limb  is  rendered  ischemic  by  means  of  a  v.  Esmarch 
bandage.  One  of  the  main  veins  is  exposed,  a  cannula  is  inserted,  and 
by  means  of  a  syringe  50  c.  cm.  of  5  per  cent  novocain  solution  is  in- 
jected toward  the  distal  portion  of  the  limb.  Complete  anesthesia  of  the 
entire  limb  is  maintained  until  the  constricting  bandage  is  removed, 
when  sensation  immediately  returns. 

Spinal  Analgesia. —  Spinal  analgesia  was  introduced  by  Corning  in 
1888  and  made  practicable  as  a  result  of  the  labors  of  Bier  (1899), 
Its  use  is  indicated  in  old  persons  with  degenerated  heart  muscle, 
arteriosclerosis,  or  chronic  bronchitis;  also  in  obese  persons  or  in 
diabetics,  in  operations  below  the  diaphragm. 

Subdural  injection  should  not  be  attempted  unless  rigid  asepsis  is 
available.  "When  shock  already  exists  the  method  accentuates  it;  it 
will,  however,  delay  or  obviate  the  occurrence  of  the  shock  attendant 
upon  operative  measures.  In  the  presence  of  low  blood  pressure  the 
method  may  be  regarded  as  exceedingly  dangerous.  xVn  objection  of 
considerable  import  is  that  (as  in  rectal  and  intravenous  anesthesia) 


142  WOUNDS 

the  occurrence  of  untoward  symptoms  may  not  be  followed  by  prompt 
withdrawal  of  the  agent. 

Cocain,  tropacocain,  strovain,  and  novocain  are  the  agents  used  for 
the  purpose,  though  the  agents  most  frequently  emploj^ed  are  tropaco- 
cain and  stovain.  Bier  uses  a  solution  containing  1.3  c.  cm.  of  a  5  per 
cent  solution  of  tropacocain  with  adrenalin  hj'drochlorid  0.000,13  per 
c.  cm.  Babcock  uses  stovain  prepared  in  a  solution  of  lighter  specific 
gravity  than  that  of  the  spinal  fluid;  stovain  .08gm.,  acid  lactic  .04 
c.  cm.,  abs,  alcohol  .20  c.  cm.,  aquae  dest.  1.80  c.  cm.  This  fluid  is 
mixed  wnth  an  equal  quantity  of  the  spinal  fluid  and  introduced  into 
the  spinal  canal.  When  a  solution  of  lighter  specific  gravity  than  the 
spinal  fluid  is  used,  the  patient's  shoulders  should  be  located  two  or 
more  inches  below  the  level  of  the  hips  to  obviate  diffusion  of  the  agent 
toward  the  head.  For  operations  upon  the  lower  half  of  the  abdominal 
cavity  and  the  lower  limbs,  the  second  or  third  lumbar  space  is  used 
for  the  site  of  the  injection,  a'nd  for  operations  upon  the  perineum  the 
fourth  lumbar  space  is  used.  The  puncture  is  made  with  a  gold, 
platinum,  or  iridium  needle  about  7  cm.  in  length  and  0.1  cm.  in  diam- 
eter, into  the  lumen  of  which  a  stylet  is  fitted  to  obviate  obstruction. 
The  needle  and  syringe  should  fit  accurately,  and  no  soda  or  other 
alkali  should  be  employed  in  their  sterilization,  as  contact  of  the 
analgesic  solution  with  free  alkalis  destroys  the  properties  of  the 
former.  ' 

To  make  the  injection  the  patient  should  be  seated  squarelj^  upon 
the  operating  table,  the  arms  held  parallel  with  the  body,  the  fore- 
arms folded  against  the  abdomen,  the  chin  flexed  on  the  chest,  thus 
arching  the  back  and  separating  the  vertebrae. 

A  line  joining  the  highest  points  of  the  iliac  crests  crosses  the  fourth 
lumbar  spinous  process  (Jacoby).  See  lumbar  puncture,  Part  VIII, 
C.  i.  Once  the  fourth  lumbar  vertebra  is  located,  it  is  easy  to  find  any 
desired  intervertebral  space.  The  index  finger  of  the  left  hand  is 
placed  over  the  intervertebral  space  to  be  punctured;  the  needle  is 
one  quarter  of  an  inch  to  the  right  of  the  median  line,  and  is  slowly 
entered  in  an  inward  and  upward  direction.  When  the  point  of  the 
needle  reaches  the  intervertebral  cartilage,  the  stjdet  is  removed  and 
the  needle  is  slowly  pushed  forward  until  spinal  fluid  emerges  from 
its  proximal  end.  If  the  needle  comes  in  contact  with  bone,  it  should 
be  partially  withdrawn  and  its  direction  changed.  Several  efforts 
may  be  necessary  before  the  intent  is  accomplished.  When  the  spinal 
fluid  is  running  freely^  the  barrel  of  the  syringe  is  connected  with  the 


GENERAL  AND  LOCAL  ANESTHESIA       143 

needle  aud  the  piston  slightly  withdrawn  in  order  to  mix  the  analgesic 
agent  with  the  spinal  fluid,  and  also  to  prove  that  the  needle  is  still  in 
the  spinal  canal.  The  injection  is  then  slowly  made,  the  needle  with- 
drawn, and  the  puncture  sealed  with  sterile  collodion. 

Analgesia  should  become  manifest  in  from  three  to  five  minutes, 
extending  upward  according  to  the  point  of  puncture,  the  position  of 
the  patient,  the  volume  and  strength  of  the  agent  used,  and  the  force 
with  which  the  injection  is  made. 

Toxicity  is  manifested  by  air  hunger,  yawning,  syncope,  nausea, 
vomiting,  and  feeble  pulse.  When  toxic  symptoms  begin,  the  head 
should  be  lowered  if  a  solution  of  lighter  specific  gravity  than  the 
spinal  fluid  has  been  used;  and  the  head  raised  if  the  solution  be 
heavier.  Prolonged  toxic  sj^nptoms  call  for  the  liberal  use  of  stimu- 
lants, for  artificial  respiration,  and,  if  the  condition  be  menacing,  for 
intravenous  infusion. 


CHAPTER  XIII 

PLASTIC    SUKGEEY 

DERMOPLASTY 

Dermoplasty  relates  to  the  utilization  of  living  tissue  for  the  correc- 
tion of  deformities  of  the  surface  of  the  body  resulting  from 
congenital  defects,  disease,  or  trauma. 

In  surgery  of  this  kind,  perhaps  more  than  in  any  other,  a  success- 
ful outcome  depends  upon  painstaking  attention  to  detail  with  regard 
to  the  general  condition  of  the  patient  and  the  local  conditions  favor- 
ing aseptic  wound  repair. 

The  flap  or  flaps  used  for  the  purpose  of  repairing  the  defect  should 
be  of  sufficient  size  to  allow  for  the  contraction  of  the  tissues  attendant 
upon  healing.  The  flap  should  be  formed  of  sound  healthy  skin, 
should  contain  no  scar  tissue,  and  should  be  so  fashioned  that  its  base 
is  of  large  size,  highly  vascular,  and  but  little  twisted.  "When  feasible 
the  long  axis  of  the  flap  should  correspond  to  the  course  of  its  vascular 
supply,  and  the  base  should  be  located  as  nearly  as  possible  to  these 
vessels. 

Method  of  Transfer. —  The  methods  of  transfer  may  be  classified  into 
six  general  forms:  (1)  Sliding  in  a  direct  line.  (2)  Sliding  in  a 
curved  line.  (3)  Jumping.  (4)  Inversion  or  eversion.  (5)  The 
tagliacotian.     (6)   Epidermal  transplantation. 

SLroiNG  IN  A  Direct  Line. —  Four  varieties  characterize  this  method 
of  transfer.  The  first  consists  of  uniting  the  lips  of  an  ordinary 
incision  made  for  the  purpose  of  repair  of  adventitious  openings  in 
the  skin,  and  the  simplest  forms  of  harelip. 

The  second  variety,  called  undercutting,  consists  in  liberating  the 
edges  of  an  incision  before  drawing  them  together,  as  is  at  times  neces- 
sary in  the  adjustment  of  the  edges  of  the  wound,  when  undue  tension 
attends  their  apposition  by  suture  (excision  of  breast). 

The  third  variety  consists  in  sliding  in  a  direct  line  hy  the  aid  of 
parallel  incisions  made  at  both  sides  of  the  defect,  the  edges  of  which 
are  refreshed.     The  parallel  liberating  incisions  are  allowed  to  heal 

144 


PLASTIC  SURGERY 


145 


by  granulation  (Fig.  90).    Undercutting  at  the  edges  of  the  refreshed 
defect  lessens  the  tension  at  the  parallel  mcisions. 

In  the  fourth  variety  the  liberating  incisions  are  made  transversely, 
i.  e.,  at  right  angles  to  the  extremities  of  the  defect  or  in  the  long  axis 
of  it,  and  undercutting  is  freely  employed.     Motility  of  the  flaps  may 


Fig.  90. —  Sliding  in  a  Direct  Line. 

be  aided  and  tension  obviated  by  semilunar  liberating  incisions  (Fig. 
91).  Extensive  defects  may  be  closed  by  fashioning  flaps  from  three 
of  the  contiguous  sides  (Celsus)  as  shown  in  Fig.  92. 

Sliding  in  Curved  Line. —  Sliding  in  a  curved  line  may  be  employed 
with  flaps  having  either  curved  or  angular  borders.  In  the  former 
instance,  the  area  thus  denuded  is  closed  by  undercutting  and  repair 


Fig.  91. —  Double  Rectangular  Flaps:  Relaxation  Incisions. 


by  suture.  In  the  latter,  the  space  may  be  allowed  to  close  by  granu- 
lation. This  method  of  repair  is  especially  useful  in  the  closure  of 
triangular,  quadrilateral,  and  elliptical  openings  in  the  integument. 

Triangular  defects  are  readily  closed  by  Diefenbach's  unilateral,  or 
bilateral  flap  method  (Fig.  93).  The  technic  of  the  method  is  clearly 
shown  in  the  illustration.  Burow's  method  of  closing  extensive  tri- 
angular defects  (Fig.  94)  consists  in  making  lateral  ineisions  d  a  and 
h  d,  each  equal  in  length  to  two  thirds  of  the  width  of  the  widest 
diameter  of  the  triangular  defect.     The  flaps  d  a  c  and  c  b  d  are  freely 


146 


WOUNDS 


dissected  up  and  united  with  each  other  {a  c  to  h  c).  After  suture, 
the  superabundant  tissue  at  either  side  {a  d  e  and  h  e'  d')  is  removed 
and  the  edges  of  the  wound  sutured  (Fig.  95). 


S^■^<M^-.^'?^v^$<^^^^^ 


J 


Fig.  92. —  Sliding  in  a  Direct  Line  from  Three  Sides  of  the  Defect. 

Littenneuer  's  method  of  closing  quadrilateral  defects  by  the  curved 
sliding  process  is  indicated  in  Fig.  96.     The  procedure  is  a  simple 


Fig.  93. —  Diefenbach's  Unilateral,  and  Bilateral  Flap  Method. 


one:  The  flap  b  e  f  g  h  raised  and  rotated  so  that  the  borders  e  f  and 
a  d  are  united  with  each  other.  For  more  extensive  quadrilateral 
defects,  the  method  of  Bruns, 
though  somewhat  complex,  is  very 
effective  (Fig.  97).  In  this  the 
flaps  a  e  f  g  and  d  h  i  k  are  dis- 
sected up,  carried  downward  and 
placed  into  the  gap  a  h  c  d  hy 
uniting  the  borders  h  i  and  e  f 
with  each  other  (Fig.  98). 

Elliptical  openings  of  large  size 
may  be  closed  by  either  of  the 
methods  shown  in  Fig.  99,  a  and 
b,  which  explain  themselves. 

Jumping. —  Jumping,  as  the  name  implies,  consists  in  ''jumping" 
a  flap  connected  by  a  pedicle,  over  an  intervening  space  of  normal 
tissue.     This  may  be  done  with  or  without  twisting  the  pedicle.     If 


Fig.  94. —  Burrow's  Method. 


PLASTIC  SURGERY 


147 


Fig.  95. —  Burrow  's  Method  Completed. 


the  flap  is  not  rotated  a  greater  distance  than  45°,  undercutting  is 
freely  employed,  with  the  view  of  obviating  undue  tension  (Fig.  100). 
The  opening  a  &  c  is  closed  by  the  flap  g  f  e  d. 

Jumping  should  be  avoided  and  may  be  employed  only  when  the 
skin  area  immediately  contiguous  to  the  defect  is  not  available  for  the 
purpose. 

The  Indian  Method. —  The  In- 
dian method  originated  in  efforts 
to  replace  the  nose  and  consisted 
in  jumping  a  skin  flap  from  the 
forehead  to  the  site  of  the  lost 
organ.  Efforts  at  replacing  the 
nose  with  flaps  consisting  of  skin 
only  have  not  been  attended  with 
satisfactory  results,  the  skin 
shrinking  and  in  a  short  time  tak- 
ing on  the  appearance  of  a  shape- 
less mass. 

The  modification  of  the  Indian 
method  now  extensively  used  for 

the  repair  of  large  defects  on  the  head  and  face,  in  which  a  pedicu- 
lated  flap  is  made  out  of  the  neighboring  tissues,  resembling  in  form 
the  outline  of  the  area  to  be  repaired,  finds  favorable  application. 

This  is  taken  up  in  connection  with  the 
surgery  of  the  face  (Part  XI). 

Inversion      and      Eversion. —  These 

methods   relate   to   the    employment   of 

integument  in  the  repair  of  defects  of 

mucous  membranes  or  vice  versa,  as  in 

(7v  /  the   formation   of   new   canals   like  the 

urethra,  vagina,  and  inclosure  of  ex- 
troph}^  of  the  bladder.  This  is  taken  up 
with  the  special  operations. 

As  a  rule  mucous  membrane  takes  or^ 
more  readily  the  characteristics  of  skin 
when  eversion  U  employed,  although  inversion  of  the  skin  to  replace 
defects  in  mucous  membranes  may  be  satisfactorily  carried  out. 

The  Tagliacotian  Method. —  The  tagliacotian  or  Italian  method 
consists  in  dissecting  up  a  flap  of  skin  on  the  arm  corresponding  (with 
allowance  for  shrinkage)  to  the  size  of  the  defect,  which  remains  in 


Fig.  96. —  Litteneur's  ^Method. 


148 


WOUNDS 


connection  with  its  original  surroundings  by  a  wide  pedicle,   and 
sewing  it  in  by  its  other  three  edges 
flap  heals  to  the  edges  of  its  new 


In  from  seven  to  ten  days  the 
f 

hi 


Bruns  '  Method. 


location,  and  the  newly  developed 
blood  vessels  invade  sufficiently 
the  transplanted  flap  to  care  for 
its  nutrition.  The  pedicle  may 
then  be  severed  and  the  arm  freed 
from  its  constrained  position. 

The  disadvantage  in  the  method 
consists  particularly  in  the  differ- 
ence between  the  color  of  the  skin  contiguous  to  the  defect  and  that 
of  the  flap,  nor  is  this  compensated  for  by  time.     Especially  is  this 

objectionable  when  the  method  is 
employed  for  the  repair  of  the 
face. 

The  advantage  of  the  method 
lies  in  the  fact  that  the  flap  can  be 
made   of   any   desired   thickness, 
and  that  portions  of  bone  or  carti- 
lage may  be  implanted  beneath  it, 
if   this   be    deemed   advisable   in 
order  to  conserve  cosmetic  effect. 
Epidermal   Transplantation, 
Reverdin  Method. —  Free  epider- 
mal transplantation  was  originated  by  Reverdin^,  who  established  the 
method  of  "pin-point"  grafting.     In  this  method  small  islets   (one 
eighth  of  an  inch  in  diameter)  of  epidermis  are  raised  on  the  point 


Fig.  98. —  Bruns'  Method  Completed. 


Fig.  99. —  Closure  of  Elliptical  Defects  a  and  5. 

of  a  needle  and  cut  off  by  the  sliding  motion  of  a  sharp  knife.  These 
are  immediately  placed  upon  fresh  or  granulating  wound  surfaces  sep- 
arated about  one  quarter  of  an  inch  from  each  other. 


PLASTIC  SURGERY 


149 


Fig,  100. —  Jumping  of  Pediculated  Flap. 

The  malpighian  laj'er  of  the  graft  adheres  to  the  underlying  surface 
and  proliferates  in  all  directions  until  the  edges  of  the  ^YOund  and  the 


Fig.  101. —  Epidermal  Grafts. 
(Symmers'  Bellevue  Hospital  case). 

various  surfaces  of  grafted  epithelium  coalesce,  resulting  in  the  forma- 
tion of  new  skin.     The  method  is  especially  applicable  in  the  treat- 


FiG.  102. —  CuTTiXG  Grafts  :  Traction  Hooks. 


150 


WOUNDS 


ment  of  fresh  burns  and  of  large  granulating  surfaces.  As  the  grafts 
are  usually  autogenous  they  heal  very  readily.  Homogeneous  grafts 
may  be  used,  though  those  taken,  from  blood  relations  will  be  found 
most  serviceable. 

Thiersch's  Method. —  A  method  of  transplanting  epidermis  in 
large  strips,  devised  by  Oilier,  was  made  clinically  practical  by 
Thiersch.^  The  method  does  not  succeed  as  frequently  as  does  that 
of  Reverdin,  though  when  the  greater  portion  of  a  Thiersch  strip  dies, 
small  islands  of  epider- 
mis may  survive  and 
ultimately  act  much  like 
the  Reverdin  grafts. 
The  technic  of  the  pro- 
cedure is  simple.  The 
area  of  skin  from  which 
the  grafts  are  to  be 
taken  is  stretched  be- 
tween two  hooks,  and  a 
strip  removed  as  shown 
in  Fig.  102,  although  the 
strips  may  be  removed 
without  the  use  of  trac- 
tion hooks.  The  strips 
of  epidermis  are  cut 
with  a  sharp  flat  razor, 
the  blade  being  carried 
so  as  to  section  the 
outer  layers  of  the  skin 
by  means  of  long, 
oblique  strokes.  The 
strips  are  drawn  off  the 
blade  by  fixing  one  corner  on  the  wound  and  carefully  drawing  the 
knife  away  from  underneath. 

After  the  strips  are  in  place  they  are  subjected  to  light  pressure, 
care  being  taken  to  exclude  air  bubbles.  The  grafted  surface  is  pro- 
tected by  a  single  layer  of  gauze  moistened  with  saline  solution,  over 
which  are  placed  several  layers  of  gauze  sponges,  arranged  in  clap- 
board fashion;  or  the  surface  maj'  be  protected  by  waterproof  or 
celloidin  mull ;    or  the  grafts  may  be  covered  with  a  laj^er  of  melted 


Fig.  103. —  Excision  of  New  Growth  from  Neck. 


PLASTIC  SURGERY 


151 


paraffin,  the  latter  achieving  best,  perhaps,  the  desired  end,  i.  e., 
removal  of  the  dressing  without  disturbing  the  grafts. 

The  Thiersch  method  is  particularly  applicable  to  large  raw  sur- 
faces; it  is,  however,  not  as  useful  as  are  others  for  plastic  repair 
when  cosmetic  effect  is  to  be  taken  into  account,  as  healing  is  followed 
by  a  considerable  degree  of  contraction. 

Wolfe-Krause  Method.— The  Wolfe-Krause  method  consists  in 
detaching  flaps  of  skin  and  subcutaneous  tissue  from  more  or  less 
remote  portions  of  the  body  and  implanting  them  into  the  defect. 


Fig.  104.—  Wolfe-Kraitse  Skin  Flap  from  Thigh. 


The  flap  shrinks  immediately  subsequent  to  its  detachment,  but  does 
not  contract  after  it  has  healed  into  place  in  its  new  environment, 
where  it  becomes  permanently  elastic  and  is  movable  over  the  under- 
lying parts.  In  this  lies  the  advantage  in  the  method  over  that  of 
Thiersch,  which  suggests  that  the  Thiersch  and  Reverdin  methods 
are  best  used  for  the  repair  of  superficial  defects  (2d  degree  burns) 
and  the  Wolfe-Krause  method  where  more  extensive  loss  of  substance 
has  occurred  (Figs.  103,  104,  105). 
The  tecJimc  is  simple.     The  skin  is  dissected  up  without  the  under- 


152 


WOUNDS 


lying  layer  of  fat,  though  small  particles  of  adipose  tissue  need  not 
be  removed  at  the  expense  of  unwarranted  trauma  to  the  implant. 
Healing  of  the  flap  depends  upon  its  early  adhesion  to  its  new  bed. 
Cosmetic  effect  is  conserved  by  avoiding  projection  of  the  implant 
beyond  the  surface  of  the  contiguous  tissue.  At  times  small  blebs 
appear  upon  the  epidermal  layer  of  the  flap ;   these  should  be  incised, 


Fig.  105. —  Transplantation  of  Flap  Into  Defect  in 
Neck. 

The  portion  of  flai?  below  the  dotted  line  allows  for  shrinkage. 


and  usually  mean  only  local  necrosis.  Even  though  the  entire  flap 
appears  weeping  and  almost  eczematous,  ultimate  repair  need  not  be 
despaired  of,  since,  in  most  instances,  sufficient  insular  areas  of 
epithelium  capable  of  proliferation  remain  intact  to  accomplish  the 
intent.  Kigid  asepsis  and  complete  hemostasis  are  essential  desiderati. 
It  is  expedient  to  hold  the  implant  in  place  with  light  pressure,  and 


PLASTIC  SURGERY  153 

prevent  its  dissociation  from  its  surroundings,  with  dressings,  avoiding 
as  much  as  possible  the  use  of  sutures. 

The  method  has  proved  serviceable  when  used  to  close  immediately 
large  wound  areas  following  removal  of  a  tuberculous  focus  or  malig- 
nant disease.  Its  employment  is  not  indicated  in  cases  in  which  the 
general  condition  of  the  patient  is  greatly  impaired;  for  obvious 
reasons,  in  this  class  of  cases  better  results  are  obtained  by  jumping  or 
sliding  flaps  with  attached  bases  from  areas  contiguous  to  the  defect. 

BIBLIOGRAPHY 

1.  Reverdin.     Gaz.  des  Hop.  Paris,  1870,  No.  4. 

2.  Thiersch,     Chir.  kong.  Vehr.,  1886,  i. 


PAET  n 

INFECTIONS  OF  WOUNDS  AND  SURGICAL  INFECTIOUS 

DISEASES 


CHAPTER  I 
GENERAL   CONSIDERATIONS  REGARDING  WOUND    INFECTIONS 

Thougli  wound  infection  is  most  frequently  the  result  of  contamina- 
tion with  bacteria,  it  also  occurs  as  the  result  of  the  direct  introduction 
of  certain  poisonous  substances,  such  as  snake  venom.  It  is  therefore 
necessary  to  differentiate  between  a  pure  toxis  resulting  from  the 
entrance  into  the  general  circulation  of  a  poison  such  as  follows  snake 
bite,  and  the  general  pathological  conditions  consequent  to  the  invasion 
of  bacteria,  and  the  presence  of  poisonous  elements,  the  outcome  of 
combat  with  them.  In  some  instances  the  bacteria  themselves  rapidly 
multiply  in  the  blood  stream,  while  in  others  the  constitutional  dis- 
turbances are  due  to  absorption  of  the  products  of  infection  originat- 
ing in  the  wound.  It  is,  of  course,  not  always  possible  to  draw  a  sharp 
line  of  demarcation  as  to  the  existence  of  a,  so-called,  toxemia  and 
definite  bacteriemia.  For  instance,  in  tetanus  and  diphtheria,  and 
indeed  in  infection  with  some  of  the  pyogenic  bacteria,  the  constitu- 
tional manifestations  are  almost  entirely  the  outcome  of  absorption 
of  the  products  of  infection,  and  few  bacteria  gain  access  to  the  body 
generally,  while,  when  the  infection  is  due  to  others,  such  as  the 
anthrax  bacillus  or  to  certain  virulent  pyogenic  bacteria,  these 
organisms  circulate  in  the  blood  where  they  rapidly  multiply  and 
overwhelm  the  host,  or  are  deposited  in  certain  tissues  forming 
metastases  (pyemia). 

General  toxic  infection  (variously  called  sepsis,  septic  intoxication, 
sapremia,  or  septicemia)  is  due  to  the  absorption  of  the  products  of 
septic  or  putrefactive  wound  infection,  though  no  doubt  to  some 
extent  bacteria  are  also  taken  up  by  the  circulating  fluid.  Based  on 
the  similarity  of  clinical  manifestations  attendant  upon  toxicemia 
per  se  and  bacteremia,  the  names  sepsis  and  septicemia  are  applied 
to  both  conditions.  Indeed,  an  effort  has  been  made  to  include  in  the 
general  term  of  sepsis  the  constitutional  expressions  of  infection  with 
bacteria  generally;  that  is,  pus  organisms,  the  various  pest  bacilli, 
and  even  the  Plasmodium  malariae.     This  is  an  objectionable  concep- 

157 


158  INFECTIONS  OF  WOUNDS 

tion ;  not  only  is  it  pathologically  incorrect,  but  clinically  would  lead 
to  the  notion  that  systemic  bacterial  invasion  occurred  with  all  wound 
infections,  most  of  which  are  not  attended  with  bacterial  invasion  of 
the  blood,  indeed,  restitution  to  the  normal  not  infrequently  taking 
place  without  destruction  of  tissue. 

It  is  submitted  that  the  terms  **  sepsis  "  and  ^'  septicemia  "  may  be 
advantageously  eliminated  from  the  terminology  of  surgical  infection, 
and  that  the  term  putrefactive  infection  be  applied  to  the  phenomena 
attendant  upon  the  gangrenous  destruction  of  tissue,  while  the  con- 
stitutional manifestations  due  to  the  absorption  of  the  products  of 
putrid  infection  (dominantly  toxemic  —  slightly  bacteremic)  be 
termed  general  putrefactive  infection.  This  leaves  unaffected  the 
conception  of  a  true  bacteremia  which  should  be  properly  described  in 
connection  with  the  particular  organism  present  in  the  blood,  a  true 
pj^emia  consisting  of  pyogenic  organisms  in  the  blood  with  or  without 
metastases. 

It  is  perhaps  not  looking  too  far  into  the  future  to  say  that  the 
term  "  pyemia  "  will  disappear,  and  that  the  invasion  of  the  blood 
current  by  bacteria  will  be  termed,  in  accord  with  the  special  organism 
present,  as  streptococcemia,  staphylococcemia,  pneumococcemia,  etc., 
or  when  mixed  infection  occurs  the  names  of  the  organisms  be 
coupled,  as  for  instance  strepto-staphylococcemia,  etc.  For  the  pres- 
ent the  term  "  pyemia  "  may  be  regarded  as  descriptive  of  the  pres- 
ence in  the  blood  of  pyogenic  organisms  only. 

Infections  due  to  a  single  kind  of  bacterium  are  called  mono-infec- 
tions, when  due  to  more  than  one  bacterium,  mixed  infections,  and 
when  several  bacteria  are  present,  poly -infections.  In  instances  where 
mono-infection  exists  and  an  additional  bacterium  makes  its  appear- 
ance it  is  called  secondary  infection;  secondary  infection  with  bacteria 
similar  to  the  one  already  present  is  called  reinfection. 

Surgical  infections  are  most  commonly  caused  by  contamination 
with  bacteria.  Bacteria  are  unicellular  parasites  belonging  to  the 
vegetable  kingdom,  which  multiply  by  fission,  hence  the  name  schizo- 
mj^cetes.  The  phenomena  consequent  to  their  invasion  are  the  outcome 
of  the  development  of  toxic  substances  resulting  from  their  action  upon 
living  tissue.  To  a  small  extent  their  effect  upon  living  tissue  is  due 
to  their  rapid  multiplication  and  consequent  mechanical  obstruction 
of  capillary  blood  vessels. 

The  poisonous  substances  (toxins)  are  of  two  kinds,  those  arising 
from  the  changes  the  bacteria  cause  in  the  tissues    (including  the 


CONSIDERATIONS  OF  WOUND  INFECTIONS  159 

blood)  of  the  host,  and  those  arising  from  the  bacteria  themselves. 
When  a  bacterial  culture  is  filtered  through  porcelain,  and  the  filtrate 
injected  into  the  circulation,  the  same  symptomology  develops  in  the 
injected  animal  as  obtains  when  the  bacteria  directly  invade  the 
tissues,  while  injection  of  the  residual  bacteria  fails  to  produce  similar 
effects;  consequently  the  toxic  substance  must  be  contained  in  the 
secretion  product  in  the  culture  medium.  As  already  stated,  these 
poisonous  substances  are  called  toxins,  the  exact  chemical  nature  of 
which  is  unknown.  They  probably  do  not  belong  to  the  albuminoids, 
but  are  closely  related  to  the  ferments.  They  are  exceedingly  sus- 
ceptible to  chemical  action,  are  unable  to  resist  a  higher  degree  of 
temperature  than  80° C,  and  slowly  decompose  at  from  50° C.  to 
60° C.  Their  most  persistent  characteristic  lies  in  the  fact  that  a  given 
bacterium  always  produces  the  same  specific  action,  giving  rise  to  the 
formation  of  the  same  toxin.  The  toxins  of  many  bacteria  (staphy- 
lococci and  streptococci,  tetanus  bacilli)  contain  substances  capable 
of  destroying  red  blood  corpuscles  (hemolysins)  or  cause  them  to 
gather  in  clumps  {agglutinins) .  Experimentation  suggests  that  these 
substances  are  of  various  kinds,  the  staphylococcus  pyogenes  aureus, 
for  instance,  liberating  a  toxin  (leukocidin)  destructive  to  white  blood 
corpuscles. 

The  second  kind  of  bacterial  poison  consists  of  the  elements  of  the 
microorganisms  themselves,  and  is  given  up  when  these  minute  bodies 
die.  Their  action  is  not  specific,  and  would  seem  to  be  the  same  for 
all  bacteria. 

The  disturbances  consequent  to  bacterial  wound  infection  may  be 
divided  into  two  classes,  local,  and  constitutional. 


CHAPTER  II 
THE   LOCAL   DISTUEBANCES   IN  WOUND   INFECTION 

"When  bacteria  enter  the  tissues  {invasion)  their  presence  does  not 
become  immediately  manifest.  It  is  necessary  that  the  invading 
horde  adapt  itself  to  its  new  environment,  and  that  the  bactericidal 
capability  of  the  v^ound  secretions  be  overcome.  This  period  of  incu- 
bation is  modified  by  the  virulence  and  the  dosage  of  the  invading 
microbes,  requiring  only  a  few  hours  —  when  the  infecting  bacteria 
are  derived  from  active  processes  such  as  peritonitis,  phlegmon, 
meningitis,  etc.  —  though  the  period  of  incubation  of  pyogenic  organ- 
isms rarely  exceeds  twenty-four  hours.  On  the  other  hand,  bacteria 
may  not  possess  sufficient  virulence  to  develop  infection,  but  are 
destroyed  by  the  bactericidial  action  of  the  wound  secretions. 

It  would  seem  to  have  been  shown  that  bacteria  are  capable  of 
converting  certain  secretions  into  a  substance  {aggressin)  capable  of 
lessening  the  resistance  of  the  tissues  and  of  delaying  phagocytosis, 
an  action  designated  as  negative  chemotaxis,  which  of  course  creates 
vulnerability  to  bacterial  invasion.  It  is  believed  that  the  aggressins 
are  capable  of  converting  ineffective  doses  of  bacteria  into  pathogenic 
ones.  As  aggressins  are  found  in  extracts  of  bacteria,  in  distilled 
water,  or  serum,  Wassermann^  suggests  that  they  originate  from  the 
elements  of  the  bacteria  themselves,  and  are  not  the  product  of  their 
activities  in  connection  with  their  culture  media.  Animals  have  been 
immunized  against  certain  bacteria  by  means  of  bacteria  free  exudates, 
and  the  antiaggressin  serum  of  these  animals  used  to  protect  others 
against  infection.  In  this  way  immunity  was  created  with  greater 
certainty  than  obtained  from  the  use  of  immunizing  sera  produced  by 
means  of  weakened  or  killed  bacteria.  In  connection  with  the  absorp- 
tion of  inflammatory  exudates,  the  behavior  of  these  substances  must 
be  taken  into  account. 

Bacterial  toxins  destroy  the  cellular  elements  of  tissues  and  at  the 
same  time  exercise  a  focal  irritation  which  is  promptly  followed  by  a 
series  of  protective  phenomena,  the  activity  of  which  is  expressed  by 

160 


LOCAL  DISTURBANCES  IN  WOUND  INFECTION      161 

the  degree  of  the  disturbances  made  manifest.  Virulent  infections  are 
attended  with  severe  reactions  if  the  liost  be  capable  of  marshaling  its 
forces,  while  their  invasion  is  attended  with  but  slight  reaction  when 
the  resistance  of  the  host  is  low,  or  when  immunization  has  been 
established  previously  and  the  aggressors  are  met  by  protective  sub- 
stances. 

The  local  disturhances  expressive  of  wound  infection  are  those  of 
niflammation.  These  vary  in  form  and  degree,  depending  upon  the 
local  resistance  of  the  tissues  and  the  general  resistance  of  the  host ; 
so  that  bacteria  of  the  same  class  will  not  produce  similar  manifesta- 
tions in  different  individuals.  Under  varying  conditions  streptococci 
of  the  same  degree  of  virulence  may  provoke  either  fibrinous,  serous,  or 
purulent  inflammatory  exudates.  Again,  the  local  reaction  may  differ 
in  accord  with  the  kind  of  bacteria  present,  as  illustrated  by  the  vary- 
ing response,  provoked  by  the  invasion  of  pyogenic  organisms 
(diphtheria,  tubercle  bacilli,  etc.).  A  pure  toxic  infection,  such  as  fol- 
lows invasion  with  tetanus  bacilli,  is  provocative  of  grave  constitu- 
tional manifestations,  j'Ct  the  local  disturbances  are  exceedingly  slight 
or  may  be  absent. 

Although  the  local  disturbances  of  inflammation  present  a  complex 
clinical  picture,  their  division  into  three  general  (not  clearly  defined) 
classes  is  possible.    These  manifestations  attend  bacterial  invasion, 

BUT  ALSO  MAY  BE  PROVOKED  BY  MECHANICAL,  THERMIC,  OR  CHEMICAL 
IRRITATION. 

The  three  classes  of  local  manifestations  may  be  expressed  as  fol- 
lows: (1)  Disturbances  of  the  circulation,  with  the  formation  of 
exudates.     (2)     Degenerative  changes.     (3)  Regenerative  changes. 

The  disturhances  of  the  circulation  may  be  observed  in  the  mesen- 
tery of  the  frog  (or  other  animal)  under  the  microscope,  being  readily 
discernible  as  the  result  of  the  irritation  due  to  contact  with  the  air, 
though  the}^  become  more  manifest  following  the  application  of  acids, 
etc.  The  primary  pathological  phenomenon  is  an  active  hyperemia  due 
to  paralysis  of  the  nerve  elements  and  abolition  of  the  contractilitj^  of 
the  blood  vessels,  which  in  turn  lessens  the  tension  of  the  surrounding 
tissues  (Landerer^).  The  flow  of  the  blood  stream  is  at  first  acceler- 
ated, due  to  the  widening  of  the  bed  of  the  arteries,  capillaries  and 
veins;  very  soon,  however,  a  slowing  of  the  circulation  at  the  edges 
of  the  stream  occurs,  and  the  active  hj'peremia  becomes  a  passive  one. 
The  damaged  vessel  walls,  made  permeable  by  the  trauma,  permit  of 
the  escape  of  transudates,  and,  despite  the  accelerated  flow  in  the 


162 


INFECTIONS  OF  WOUNDS 


lymphatics,  the  pressure  in  the  tissues  is  increasingly  obstructing  the 
flow  of  the  circulating  fluid  through  the  veins  to  a  varying  degree,  at 
times  reaching  the  extent  of  complete  stasis. 

The  actual  formation  of  exudates  is  preceded  by  stasis  of  the  white 
blood  corpuscles  which  accumulate  in  the  capillaries.  As  soon  as  the 
flow  of  blood  in  the  veins  is  slowed,  the  leukoc}i:es  are  clearly  discern- 
ible in  the  plasma  at  the  edges  of  the  stream,  whilst  the  heavier  red 
blood  corpuscles  remain  in  the  center.  The  leukocytes  roll  indolently 
onward,  being  propelled  with  less  and  less  force  until  arrested,  at 


Fig.  106. —  The  "Vascul-Ui  Phenoiiexa  of  Inflammation. 

Leukocytes  at  periphery  of  vessel ;  rod  corpuscles  in  center 
of  stream.  A  few  of  both  have  migrated  into  the  tissues 
contiguous  to  the  vessel. 


first  singly  and  later  in  layers,  along  the  vessel  wall.  Soon  the  phe- 
nomena of  migration  described  bj'  Cohnheim  occur;  the  leukocytes, 
endowed  with  amebic  properties,  send  forth  projections  of  protoplasm 
which  penetrate  between  the  damaged  endothelial  vessel  cells  and 
gradually  the  entire  leukoc}i:e  migrates  through  the  vessel  wall,  to 
wander  into  the  highway's  and  byways  of  the  surrounding  tissues 
(Fig.  106). 

These  phenomena,  the  migration  of  the  leukocytes  and  the  trans- 
udation of  fluid  from  the  vessel,  are  the  outcome  of  inflammatory 
irritation.    The  tendency  of  leukocytes,  or  other  cellular  elements  cap- 


LOCAL  DISTURBANCES  IN  WOUND  INFECTION     163 

able  of  motion,  to  be  attracted  by  bacterial  toxins  and  proteins  is 
called  positive  chemotaxis. 

Simultaneously  with  the  migration  of  leukocytes  ixto  the 

AREA    OF    IXFLAMMATIOX,   THE    TISSUES    ARE    DISTENDED    WITH    EXUDATE 

WHICH  INFILTRATES  ITS  MESHES.  The  exudate  transudes  because  of  the 
increased  permeability  of  the  blood  vessel  walls  (due  to  trauma)  and 
also  because  of  the  lessened  tension  of  the  walls  of  the  capillaries 
(Korner^,  Landerer-).  It  is  not  improbable  that  at  first  there  is 
simpl}"  an  increase  in  filtration  and  diffusion,  the  activity  of  the  dif- 
fusion stream  depending  upon  the  difference  in  the  osmotic  pressure  of 
the  blood,  as  compared  to  that  of  tissue  fluid,  it  being  increased  in 
proportion  to  the  concentration  of  the  latter  (Cohnstein*,  Klemen- 
siewicz'').  It  is  a  question  what  influence,  if  any,  the  so-called  secre- 
tory function  of  the  capillaries  (Heidenhain^)  has  in  this  connection 
(Klemenciewicz").  The  transuded  fluid  unquestionably  contains  sub- 
Rtances  which  normally  do  not  permeate  blood  vessels,  but  are  retained 
in  the  blood.  The  inflammatory  exudate  differs  from  lymph,  in  that  it 
contains  a  much  greater  number  of  cellular  elements,  and  almost  equals 
the  blood  in  albumin  content.  Exudation  results  in  the  formation 
of  a  hard,  tense,  hyperemic  focus  called  the  inflammatory  infiltrate 
v^•hich  is  surrounded  by  a  less  tense  area  of  inflammatory  edema. 

These  phenomena  are  accompanied  by  important  biochemical  activi- 
ties which  are  concerned  in  protecting  the  menaced  tissues.  In 
instances  of  non-bacterial  inflammatory  processes,  the  necrotic  tissues 
simply  undergo  liquefaction  that  renders  them  absorbable,  whilst  the 
activities  consequent  to  infection  involve  also  the  formation  of  sub- 
stances which,  together  with  the  phagoc}i:ic  action  of  the  leukocytes, 
are  concerned  in  the  destruction  of  the  invading  bacteria. 

The  cellular  elements  concerned  in  migration  are  chiefly  poly  nu- 
clear leukocytes  (originating  in  bone  marrow  —  Ehrlich)  ;  some  red 
hlood  corpuscles,  which  migrate  hy  diupedesis  or  rhexis  when  the 
blood  vessels  are  seriously  damaged;  lymphocytes  and  eosinophilic 
leukocytes.  Since  the  lymphocytes  are  found  arranged  in  small  foci 
close  to  the  blood  vessels,  it  is  suggested  that  they  are  concerned  in 
the  absorption  of  certain  poisonous  products  (Ribbert"). 

The  degenerative  and  necrotic  changes  in  inflamed  areas  are  the 
outcome  of  the  action  of  bacterial  poisons,  and  of  mechanical,  thermal, 
or  chemical  influences,  each  of  which  modifles  the  vitality  of  the 
tissues  and  often  totally  destroys  them,  although  this  destruction  is 
also  the  result  of  circulatory  and  nutritive  disturbances  due  to  the 


.164  INFECTIONS  OF  WOUNDS 

presisure  of  the  infiltrate,  the  capillary  stasis  and  thrombosis  of  the 
inflamed  arterioles  and  veins. 

Necrotic  tissue  is  liquefied  by  the  activities  of  the  leukocytes  and 
the  ferments  liberated  upon  their  death,  a  process  which  is,  however, 
rarely  sufficient  to  render  absorbable  the  entire  quantity  of  dead  sub- 
stance, so  that  expulsion  through  natural  channels  (sinuses,  etc.),  or 
removal  by  artificial  means  (incision,  excision,  etc.)  is  necessary. 

Regenerative  changes  begin  about  twelve  hours  after  the  develop- 
ment of  the  so-called  inflammatory  processes ;  that  is  to  say,  degener- 
ative changes  are  practically  met  at  once  by  regeneration;  the  latter 
consisting  of  connective  tissue  hyperplasia,  proliferation  of  endothelial 
cells,  lymph  cells,  and  blood  vessels,  a  rapid  increase  of  cell  proto- 
. plasm,  and  the  formation  of  numerous  karyokinetic  figures.  At  the 
same  time,  the  field  is  invaded  by  quantities  of  round  uninuclear  cells, 
designated  by  Unna  as  plasma  cells,  and  generally  regarded  as  spring- 
ing from  the  tissue  Ijnnphocytes  (Schatfer^),  though  their  exact 
origin  is  still  unknown. 

Cell  procreation  dominates  as  hyperemia  and  the  transudation  of 
exudate  diminishes  and  gradually  leads  to  the  development  of  granu- 
lation tissue,  which  latter  consists  of  fibroblasts,  leukocytes,  lympho- 
cytes, and  newly  formed  blood  vessels,  a  process  that  differs  in  no 
essential  particular  from  what  takes  place  in  the  healing  of  wounds. 
.-Granulation  tissue  is  destined  to  replace  the  loss  of  substance  con- 
sequent to  the  necrosis  and  absorption  resulting  from  the  inflammatory 
.process.  For  this  reason  granulation  tissue  is  found  at  the  edges  of 
•inflammatory  areas  of  ulcers  of  the  skin  and  mucosa  in  the  vicinity  of 
bone  sequestra;  in  the  walls  of  abscesses;  and  in  the  lining  of  the 
lumen  of  fistulge  and  sinuses. 

Granulations  surround  and  mechanically  loosen  gangrenous  areas, 
and  also  furnish  a  secretion  which,  when  bacteria  are  present,  is  rich 
in  leukocytes  that  are  concerned  in  the  formation  of  a  ferment  capable 
of  digesting  necrosed  tissues.  Under  these  conditions  granulation 
tissue  ultimately  forms  scar  tissue  in  precisely  the  same  way  as  obtains 
in  the  healing  of  wounds. 

Acute  inflammatory  processes  are  characterized  by  the  manifesta- 
tions classic  in  the  literature  since  Galen :  Ruber,  Tumor,  Calor,  Dolor, 
and  Functio  Laesa.  Redness  and  heat  are  due  to  the  active  hyper- 
emia; the  swelling  is  caused  by  the  accumulation  of  exudate;  pain 
is  the  result  of  the  action  of  bacterial  poisons  and  other  pernicious 
substances  upon  the  nerve  endings  together  with  the  mechanical  pres- 


LOCAL  DISTURBANCES  IN  WOUND  INFECTION     165 

sure  of  the  exudate;  and  loss  of  function  is  the  outcome  of  swelling 
and  pain. 

Variations  in  degree  of  these  manifestations  accord  with  modifica- 
tions in  the  virulence  and  the  character  of  the  causative  factor.  In 
some  instances  lavage  of  the  affected  part  with  transudate,  and  an 
increase  in  the  rapidity  of  the  blood  stream,  suffices  to  remove  the 
disturbing  cause  and  complete  restitution  to  the  normal  promptly 
results  (Landerer-).  In  other  instances  the  manifestations  of  mflam- 
mation  become  full}'  developed,  hyperemia  and  the  appearance  of 
exudate,  degeneration  and  necrosis  occur  and  lead  to  the  sequelae  con- 
sequent to  virulent  (pj'ogenic)  processes,  or  trauma  (severe  thermal 
or  chemical  burns)  ;  and  in  still  others  (syphilis,  actinomycosis,  tuber- 
culosis) active  tissue  cell  putrefaction  takes  place. 

Acute  inflammatory  processes  are  attended  by  very  active  hyper- 
emia and  the  rapid  formation  of  exudate,  and  usually  follow  a  stormy 
course ;  while  chronic  processes  are  more  likely  to  be  accompanied  b}' 
the  formation  of  connective  tissue.  Acute  processes  not  infrequently 
become  subacute  or  chronic.  When  the  manifestations  of  inflamma- 
tion are  not  sufficientl}^  active  to  be  called  acute,  and  are  not  attended 
with  the  indolence  of  chronicity,  the  term  subacute  is  employed.  Re- 
iicwed  virulence  on  the  part  of  the  bacteria,  or  lessened  resistance  on 
the  part  of  the  host,  may  cause  a  subacute  or  chronic  process  to  flare 
into  an  acute  exacerbation. 

The  character  of  exudate  and  the  extent  of  tissue  necrosis  maj'  be 
regarded  as  the  most  important  indications  in  standardizing  the 
virulence  of  inflammatory  processes.  On  this  basis,  the  following 
forms  of  inflammation  may  be  recognized :  Serous,  fibrinous,  puru- 
lent, hemorrhagic  and  gangrenous. 

Serous  inflammation  is  attended  with  a  watery  exudate,  rich  in 
albumen  containing  few  cellular  elements.  When  mucous  membranes 
are  involved  the  exudate  is  watery  mixed  with  mucous  {catarrhal  in- 
flammation) ;  in  the  skin  it  finds  expression  in  the  formation  of 
serous  blebs,  and  in  the  subcutaneous  tissue  forms  an  inflammatory 
edema.  In  the  larger  serous  cavities  {pleura,  peritoneum,  etc.),  in 
the  serosa  of  the  joints  and  of  bursac,  it  gives  rise  to  a  similar  trans- 
udate. Depending  upon  the  character  of  bacterial  invasion,  serous 
inflammation  may  be  acute  (erysipelas),  or  chronic  (tuberculosis  of 
serous  cavities),  and,  dependent  upon  the  grade  of  virulence  of  the 
process,  it  takes  a  mild  course  {osteomyelitis  albuminosa),  or  it  may 
take  ?  severe  form  due  to  pyogenic  bacterial  infection  {seropurulent 


166  INFECTIONS  OF  WOUNDS 

phlegmon).  Frequently  the  exudate,  being  primarily  purely  serous, 
becomes  rich  in  fibrin  and,  together  with  the  increase  of  cell  content, 
merges  into  the  fibrinous  or  purulent  forms. 

Fibrinous  inflammation  is  characterized  by  coagulation  of  the 
albuminoids  held  in  solution  in  the  exudate.  This  coagulation  prob' 
ably  results  from  the  action  of  ferments  given  up  upon  the  death  of 
certain  cellular  elements,  chiefly  leukocytes.  Deposit  of  fibrinous 
exudate  occurs  upon  the  surfaces  of  serous  and  mucous  meuibranes, 
upon  ulcers  of  the  skin,  and  in  the  alveoli  of  the  lungs,  rarely  in  the 
tissues  themselves.  It  is  coincident  with  the  death  of  tissue  {coagu- 
lation necrosis)  and  frequently  accompanies  purulent  inflammatory 
processes.  When  located  upon  mucous  surfaces  it  forms  a  gray  or 
yellowish  white  deposit.  This  fibrinous  or  croupous  false  membrane 
occurs  in  diphtheria,  and  also  in  infections  of  mucous  membrane  with 
staphylo-,  pneumo-,  streptococci,  and  bacillus  typhosus.  The  false 
membrane  is  easily  removed  when  only  the  epithelial  covering  is 
involved,  as  shown  in  cases  of  bronchial  diphtheria,  in  which  a  cast  of 
the  entire  bronchial  tree  is  not  infrequently  expelled  by  the  act  of 
coughing.  When,  however,  the  exudate  penetrates  to  the  deeper 
layers  of  the  mucous  membrane,  its  residence  is  not  so  easily  disturbed 
(pharyngeal  diphtheria) .  Involvement  of  serous  membranes  (periton- 
eum, synovia,  etc.)  is  characterized  in  much  the  same  manner,  that  is, 
the  fibrinous  deposit  is  at  first  loosely  attached  and  later  forms  a 
closely  adherent  layer,  difficult  to  differentiate  from  the  thickened 
membrane  itself.  Fibrinous  exudate  attendant  upon  tuberculous 
involvement  of  joiiit  surfaces  and  bursae  is  exceedingly  tenacious. 
When  it  is  torn  off  in  small  particles,  as  the  result  of  movements  of 
the  affected  parts,  it  forms  small  hard  kernels  (rice  bodies).  Granu- 
lating ulcers  of  the  skin  are  frequently  the  site  of  fibrinous  deposits, 
due  to  infection  with  various  pyogenic  organisms,  including  diph- 
theria. The  presence  of  free  fibrin  flakes  in  a  serous  or  seropurulent 
exudate  is  indicative  of  tuberculosis.  Microscopically  fibrinous 
exudate  consists  of  a  closely  woven  network  of  fibrils,  the  meshes  of 
which  are  filled  with  eiDithelial  and  connective  tissue  cells,  leukocytes, 
platelets,  and  colonies  of  bacteria. 

Purulent  exudate  is  characterized  by  a  yellow  creamy  exudate 
widely  recognized  as  pus.  The  pus  of  infected  mucous  surfaces  is 
mixed  with  mucous  secretion.  Pus  is  contained  in  pustular  skin  blebs, 
and  appears  as  an  exudate  in  the  spaces  formed  by  the  breaking 
down  of  tissue  elements,  and  it  is  also  found  free  in  serous  cavities 


LOCAL  DISTURBANCES  IN  WOUND  INFECTION     167 

(empyema).  The  distiuctive  feature  of  purulent  exudate  lies  iu  the 
magnitude  of  its  cell  content,  chiefly  polynuclear  neutrophils  (pus 
corpuscles).  Pus  retained  in  the  body  for  a  considerable  period  of 
time  also  contains  elements  that  are  the  product  of  the  action  of 
bacterial  poisons  upon  the  tissues  themselves.  This  destruction  of 
tissue  extends  by  contiguity  as  the  outcome  of  the  action  of  certain 
ferments  liberated  by  the  leukocytes  upon  their  death  (Miiller^) .  Pus 
resulting  from  the  prolonged  action  of  pyogenic  infection  contains 
various  cellular  elements :  Fresh  and  old  leukocj'tes,  connective  tissue 
cells,  lymphocytes,  red  blood  corpuscles,  and  epithelial  cells,  all  of 
which  exist  in  a  more  or  less  degenerated  state ;  also,  in  some  instances, 
the  exudate  contains  necrotic  connective  tissue  fiber  and  bone  detritous. 
The  proteolytic  leuloci/te  ferment  is  furnished  by  poh-nuclear  neutro- 
philic leukocytes,  and  is  capable  of  action  not  unlike  that  of  pancreo- 
trypsin  (Jochmann^°). 

Pyogenic  microorganisms  are  the  chief  cause  of  purulent  inflam- 
mation. It  is  true  that,  experimentally,  injection  of  certain  chemical 
substances  (turpentine,  mercury,  petroleum,  etc.),  or  the  introduction 
into  the  body  of  necrosed  tissue  may  produce  purulent  inflammation ; 
however,  under  the  latter  condition  the  process  is  never  progressive, 
hut  is  restricted  to  the  site  of  the  injection.  Purulent  exudate 
infrequently  contains  fibrin ;  though  the  reason  for  this  is  not  clear, 
it  is  believed  that  bacterial  poisons  interfere  with  coagulation.  Fibrino- 
purulent  exudate  attends  tuberculous  processes,  and  is  found  in  puru- 
lent inflammations  of  serous  cavities  and  joints. 

Inflammation  attended  with  the  formation  of  a  thin,  yellow  translu- 
cent fluid  exudate  is  called  seropurulent. 

The  character  of  2^!'5  varies  with  the  causative  factor.  Staphy- 
lococci produce  a  creamy  yellow  pus ;  strepto-  and  pneumococcus  pus  is 
thin,  fluid,  and  of  a  yellowish  green  color ;  pus  containing  the  bacillus 
pyocyaneus  stains  the  skin  and  dressings  a  bluish  green ;  tuberculosis 
pus  is  watery  and  flocculent ;  that  of  t}^hoid  is  thin,  brown  in  color, 
and  contains  necrosed  tissue  particles. 

Hemorrhagic  inflammation  is  characterized  by  the  presence  of  blood, 
which  may  occur  in  any  one  of  the  exudates  previously  described. 
Blood  is  found  in  the  exudate  of  tuberculous  pleuritis  and  pericar- 
ditis, of  general  hemorrhagic  infections,  and  in  instances  of  very  severe 
processes  involving  mucous  membranes. 

Putrid  inflammation  is  the  result  of  infection  with  putrefactive 
organisms  and  causes  gangrene  of  the  involved  tissue.    The  resultant 


168  INFECTIONS  OF  WOUNDS 

exudate  is  at  first  serous,  and  later  hemorrhagic,  contains  masses  of 
broken  down  tissue,  and  is  not  unlike  spleen  pulp  in  appearance. 
The  infected  area  gives  off  a  foul  odor  (anthrax). 

Tissue  necrosis  occurs  in  various  forms  of  inflammation,  and 
varies  in  extent  in  accord  with  the  character  of  process  present.  It 
occurs  coincident  to  all  the  various  forms  of  exudate ;  with  serous 
or  seropurulent  exudate  (severe  streptococcus  phlegmon)  ;  with  puru- 
lent exudate  (pyogenic  cocci)  ;  with  the  caseous  degeneration  of 
tuberculosis ;  and  in  putrefactive  inflammation  it  may  be  regarded  as 
the  dominant  factor.  Inflamed  and  thrombosed  blood  vessels,  espe- 
cially the  veins  and  smaller  arteries,  are  also  subject  to  necrotic  de- 
generation. When  the  walls  of  large  arteries  are  invaded  severe 
hemorrhage  occurs,  a  not  infrequent  complication  of  prolonged  viru- 
lent purulent  inflammatory  processes. 

Inflammation  may  run  an  acute  or  clironic  course  dependent  upon 
its  cause.  Concentrated  caustic  acids  provoke  more  active  inflamma- 
tory reaction  than  do  the  dilute  acids,  though  the  repeated  applica- 
tion of  the  latter  maintains  a  low  grade  of  inflammation.  This  is 
also  true  in  inflammations  caused  by  bacteria  which  produce  poison- 
ous substances,  the  action  of  which  is  not  unlike  that  of  chemical 
irritants.  Foreign  bodies,  or  retained  necrosed  tissue  (bone  seques- 
trum following  suppurative  osteomyelitis,  etc.),  are  the  source  of 
constant  irritation  to  the  surrounding  tissues,  which  are  maintained 
in  a  condition  of  chronic  inflammation,  until  the  offending  substance 
is  either  spontaneously  expelled  or  is  removed. 

While  acute  inflammation  is  provocative  of  great  hyperemia,  and 
massive  exudation,  and  is  accompanied  with  more  or  less  tissue 
necrosis,  these  phenomena  are  not  marked  characteristics  of  the 
chronic  forms;  on  the  other  hand,  chronic  inflammation  is  attended 
by  the  domination  of  tissue  regeneration,  and  is  characterized  by  pro- 
liferation of  connective  tissue,  periosteum,  and  adenoid  tissue  (ele- 
phantiasis of  the  skin,  connective  tissue  thickening  of  serous  mem- 
branes ;  hyperostosis,  chronic  tonsillar  and  lymphoid  h^^perplasia). 

In  persistent  bacterial  infection  the  proliferation  of  connective 
tissue  in  the  inflamed  part  is  sufficiently  exuberant  at  times  to  cause 
the  formation  of  nodular  excrescences  called  granulomata  (tubercu- 
losis, lues,  lepro.sy,  chronic  glanders,  actinomycosis,  rhinoscleroma), 
which  contain  enmeshed  in  their  spaces  the  special  causative  excitant 
that  gives  the  new  growth  its  specific  characteristic.  When  these 
chronic  inflammatory  processes  are  attended  with  the  formation  of 


LOCAL  DISTURBANCES  IN  WOUND  INFECTION      169 

exudate,  the  exudate  takes  ou  characteristics  peculiar  to  the  kind  of 
infection  present ;  that  is  to  say,  if  caused  by  tuberculosis,  the  exudate 
is  serous,  purulent,  scro-jHirulent,  fibrinous,  or  it  may  be  localized, 
forming"  a  cold  abscess ;  if  luetic,  the  exudate  is  serous  (hydrops  of 
joints,  etc.,  etc.). 

Chronic  interstitial  inflaniniation  in  muscles  and  organs  leads  to 
atrophy  of  the  parenchyma  of  the  part  involved  after  primary  pro- 
liferation has  been  followed  by  contraction  of  the  connective  tissue 
(contracted  kidney,  cirrhosis  of  the  liver,  etc.). 

BIBLIOGRAPHY 

1.  "Wassermanx.     Deutsch.  med.  Woch.,  1907. 

2.  Landerek.     Samml.  klin.  Vortr.,  1885,  No.  259. 

3.  KoRNER.    See  Klemensiewicz  No.  5. 

4.  ConxsTEiN.     See  Klemensiewicz  No.  5. 

5.  Klemexciewicz.    Die  Enziiuduns-,  Jena,  1908. 

6.  Heidexhaix.     Arch.  f.  Gesam,  Phys.  Bd.  49,  1891. 

7.  Ribbert.     Lehrbuch  d.  Alls'.  Path.,  Leii^zig,  1905. 

8.  Schaffer.     Zentrbl.  f.  Path.,  1909. 

9.  MiJLLER.     Miinch.  med.  Woch.,  1907. 

10.     JocHMAXX.     In  Kolle-Wassermann  Handb.  d.  path.  Mikroors:.  (2d  ed.) 
Bd.  ii,  1913. 


CHAPTER  III 

THE  GENERAL  DISTUEBANCES   IN   WOUND   INFECTION 

The   systemic    disturbances    consequent    to    infection    begin 

WITH  THE  distribution  OF  PATHOGENIC   ORGANISMS  AND  THEIR  POISONS 

THROUGHOUT  THE  BODY.  The  introduction  of  bacteria  into  a  fresh 
wound  permits  of  their  rapid  entrance  into  the  circulating  fluids,  and 
speedy  invasion  of  the  parts,  organs,  and  tissues  of  tlie  body.  Under 
these  conditions  one  must  assume  tliat  aggression  occurs  tlirough  the 
traumatized  capillaries,  though  no  doubt  absorption  through  the 
lymph  channels  also  takes  place.  Both  pathogenic  bacteria  and  harm- 
less saprophytes  gain  access  in  this  way  (Schimmelbusch^). 

Immediate  absorption  occurs  only  in  fresh  wounds  and  is  more 
common  following  incised,  than  obtains  with  contused  or  lacerated 
wounds.  Older  wounds  already  covered  with  plasma,  burns,  and 
granulating  wounds  do  not  become  infected,  though  the  latter  may 
give  entrance  to  infection  when  there  is  a  solution  of  continuity  in  the 
granulation  tissue  (practically  equivalent  to  the  production  of  a 
fresh  wound).  Uninjured  mucous  membranes  and  serous  surfaces 
are  susceptible  to  the  penetration  of  virulent  pathogenic  organisms 
that  are  rapidly  absorbed.  Immediate  absorption  of  bacteria  is  not 
infrequently  supplemented  later  on  by  a  secondary  invasion  on  the 
part  of  the  excitants  by  way  of  the  lymph  and  blood  vessels.  Bacteria 
gain  access  to  the  general  system  (blood  and  lymphatics)  through 
fresh  wounds  before  inflammatory  reaction  develops  at  the  port  of 
entrance  and  are  destroyed  by  bactericidal  substances  in  the  body. 
The  local  defense  develops  in  the  meantime,  and  restitution  to  the 
normal  is  made  possible.  In  this  way  the  milder  forms  of  infection 
are  taken  care  of.  It  has  been  assumed  that  a  physiological  elimina- 
tion of  bacteria  through  the  kidneys,  lymph  nodes,  sweat  glands,  etc., 
takes  place  without  the  occurrence  of  pathological  changes  in  these 
organs.  This  assumption  has,  however,  been  found  to  be  erroneous 
(NotzeP). 

The    DEGREE    OF    VIRULENCE    OF    THE    BACTERIAL    AGGRESSORS    DETER- 

170 


GENERAL  DISTURBANCES  IN  WOUND  INFECTION      171 

MINES  WHETHER  THE  CLINICAL  MANIFESTATIONS  OF  SYSTEMIC  DIS- 
TURBANCES OCCUR  EARLY  OR  LATE,  OR  FAIL  TO  APPEAR.      The  absorption 

of  hig-lily  virulent  bacteria,  especially  those  directly  transmitted  from 
a  diseased  focus  in  the  human,  provokes  immediate  systemic  re- 
sponse ;  those  mildly  virulent,  such  as  originate  outside  the  body,  must 
first  accommodate  themselves  to  the  invaded  tissues,  multiply  (period 
of  incubation),  and  overcome  the  bactericidal  forces  of  the  host  before 
they  are  absorbed  by  the  circulation  in  sufficient  quantity  to  provoke 
systemic  manifestations.  Not  infrequently  the  bacterial  flora  at 
the  port  of  entrance  is  not  sufficiently  active  to  give  constitutional 
evidence  of  its  presence. 

When  bacteria  enter  the  circulation  and  are  not  destroyed  because 
of  their  virulence,  because  of  their  overwhelming  numbers,  or  because 
of  a  lack  of  resistance  on  part  of  the  host,  they  are,  in  some  instances, 
deposited  or  settle  in  the  bone  marrow,  spleen,  liver,  or  other  portions 
of  the  body  where  they  develop  metastases;  w^hile  in  other  instances 
they  multiply  with  such  rapidity  as  to  permeate  the  entire  circulation 
of  the  body  (bacteriemia). 

These  phenomena  vary  with  the  kind  of  bacteria  present;  all  of 
them  occur  with  purulent  infections;  glanders  is  attended  with 
metastases;  anthrax  gives  rise  to  general  infection;  in  tetanus  and 
diphtheria  the  aggressors  invade  the  circulation  to  a  very  slight  extent ; 
tuberculosis  spreads  by  metastases  to  a  greater  or  less  degree  as  shown 
in  miliary  tuberculosis. 

The  most  severe  forms  of  general  bacterial  infection,  accompanied 
by  rapid  multiplication  of  bacterial  aggressors  in  the  blood,  occur 
when  the  body  is  no  longer  capable  of  producing  natural  bactericidal 
substances.  The  term  "bactericide"  is  applied  to  all  substances 
capable  of  destroying  bacteria.  These  substances  exist  normally  in 
the  lymph  and  in  the  blood,  and  their  activity  depends  upon  the 
presence  of  certain  cellular  elements,  especially  leukocytes.  Natural 
resistance  to  infection  is  largely  dependent  upon  their  activities  in 
the  body. 

Fresh  blood  serum  draivn  from  the  healthy  body  contains  substances 
that  possess  the  ability  to  dissolve  or  to  cause  coalescence  (agglutina- 
tion) of  various  kinds  of  bacteria  and  the  blood  corpuscles  of  animals 
of  other  species.  These  substances,  in  accord  with  their  special  action, 
are  called  bad erioly sins,  hemolysins,  bacterio-agglutinlns,  or  hemagglu- 
iinins.  According  to  Buchner^,  this  action  is  dependent  upon  the 
presence   in    the  serum   of   an   albuminoid   substance   called   alexin 


172  INFECTIONS  OF  WOUNDS 

(defender).  Alexin  is  an  exceedingly  unstable  substance,  soon  losing 
it  charactfiristics  after  the  serum  is  withdrawn  from  the  body;  it  is 
incapable  of  withstanding  a  temperature  of  more  than  55 °C.  Accord- 
ing to  Ehrlich  and  Morgenroth*,  bactericidal  and  globulicidal  action 
is  not  dependent  upon  the  presence  of  alexins,  but  results  from  a 
multi-activity  on  the  part  of  several  todies.  As  the  result  of  experi- 
mentation, it  is  concluded  that  the  particular  action  of  the  serum,  in 
all  instances,  is  due  to  the  presence  of  two  bodies ;  the  very  unstable 
alexin  or  complement  (easily  destroyed  by  heat)  and  an  intermediate 
body  which  survives  the  action  of  heat.  Ehrlich  gives  this  interme- 
diate body  the  name  of  amboceptor,  because  it  unites  with  the  bacteria 
and  the  extrinsic  blood  corpuscles  on  the  one  hand,  and  on  the 
other,  combines  with  the  complement,  making  the  destructive  ferment- 
like action  of  the  latter  possible.  The  capacity  on  the  part  of  the 
complement  to  act  as  a  destructive  ferment  ceases  when  it  enters  into 
2ombination  with  bacteria  (a  characteristic  upon  which  is  based  the 
complement  binding  reaction  used  in  diagnosticating  syphilis).  How- 
ever, the  combined  action  of  the  two,  amboceptor  and  complement, 
may  not  be  regarded  as  a  constant,  as  it  depends  upon  various  forms  of 
intermediate  bodies  capable  of  varying  objectives;  not  alone  as  to 
bacteria  generally  but  as  applied  to  various  kinds  of  bacteria  (typhoid, 
cholera  bacilli,  and  blood  corpuscles  of  various  species).  A  serum 
may  agglutinate  typhoid  bacilli  and  also  cholera  bacilli,  but,  after  ac- 
complishing this  twofold  mission,  it  is  no  longer  capable  of  again 
agglutinating  typhoid  bacilli.  Complements  must  also  be  regarded  as 
compound  bodies  consisting  of  two  parts  {a  globulin  and  an  albumin 
part),  neither  of  which,  according  to  Ferrata,  is  capable  of  acting 
alone. 

Serum  whose  complement  has  been  destroyed  by  heat  is  called 
inactive.  However,  as  it  still  contains  the  intermediate  body  (ambo- 
ceptor) which,  according  to  Ehrlich,  resists  the  action  of  heat,  it  may 
be  reactivated,  developing  new  complement  when  a  small  portion  of 
normal  serum  is  added. 

Normally  the  body  contains  only  a  small  number  of  intermediate 
bodies;  when,  however,  infection  occurs  the  specific  intermediate  body 
is  constantly  produced,  so  that  when  the  infection  is  overcome  this  is 
present  in  large  quantities,  though  its  increase  is  maintained  for  only 
a  short  period  of  time.  This  increase  does  not  apply  to  all  intermediate, 
bodies  present,  but  is  limited  to  those  concerned  in  combating  a  special 
infection  (specific  bacteria,  or  cells  of  other  species) .    These  substances 


GENEEAL  DISTURBANCES  IN  WOUND  INFECTION      173 

are  called  immune  bodies,  upon  which  depends  the  specific  bactericidal 
or  globulicidal  capacity  of  immunizing  serum.  That  is  to  say,  if  an 
animal  is  immunized  against  typhoid,  its  serum  actively  destroys 
typhoid  bacilli,  but  has  no  effect  upon  other  bacteria,  as  the  specific 
immune  body  provokes  only  the  combination  of  the  tjT)hoid  bacilli 
with  the  complement,  which  latter  is  of  course  not  increased  in  amount, 
being  exhausted  in  the  combat  as  soon  as  it  is  formed. 

The  normal  quantities  of  general  and  specific  protective  substances 
P'resent  in  the  body  suffice  only  to  overcome  infections  of  moderate 
degree  of  virulence,  not  attended  with  very  great  or  rapid  multiplica- 
tion of  bacteria  in  the  blood.  "When  the  character  of  infection  is 
virulent,  the  protective  substances  are  totally  inadequate. 

A  diminuiion  of  protective  sulstances,  especially  the  complement, 
renders  the  individual  more  susceptible  to  infection.  Chronic  organic 
disease  lessens  the  quantity  of  complement  in  the  body,  and  also 
increases  susceptibilit}'  to  infection.  Observations  made  by  v.  Dongern 
v;ould  suggest  tliat  the  binding  of  complement  in  dead  tissue  explains 
the  lessened  local  resistance  following  trauma  ( frequency"  of  infection 
in  lacerated  and  contused  wounds). 

It  is  feasible  to  increase  locaUij  the  quantity  of  protective  sub- 
stances. Normally,  the  hijperemia  produced  by  the  irritation  of  every 
inflammatory  process  results  in  a  local  increase  in  the  quantity  of 
bactericidal  substances,  the  outcome  of  a  slowing  of  the  blood  stream. 
It  is  possible  to  create  a  similar  condition  of  affairs  and  to  cause  a 
local  accumulation  of  intermediate  bodies  and  complement,  and,  per- 
haps, also  to  increase  the  opsonins,  as  a  result  of  the  coincident  phago- 
cytosis, by  means  of  artificial  hj-peremia.  This  explains  the  beneficial 
effect  of  comiterirritants  upon  subacute  and  chronic  inflammatory 
processes  (tincture  of  iodin,  alcohol,  poultices,  cataplasms),  and  also 
constitutes  a  warning  against  this  procedure  in  the  presence  of  acute 
inflammation;  on  the  ground  that  the  transudation  of  exudate  is 
increased,  the  formation  of  pus  and  the  solution  of  tissue  is  hastened, 
and  the  circulatory  disturbances  are  enhanced,  thus  favoring  the 
occurrence  of  necrosis. 

Bier's  therapeutic  passive  (venous)  h^^eremia  (rubber  band  com- 
pression) in  the  treatment  of  infectious  processes,  especially  joint 
tuberculosis,  gonorrheal  arthritis,  and  acute  inflammations  generally, 
is  based  on  the  notion  that  the  increased  transudation  of  blood  plasma 
and  leukocytes  stimulates  local  bactericidal  action.  However,  the 
method  is  open  to  objection;  it  interferes  with  nutrition  and  delavs  the 


174  INFECTIONS  OF  WOUNDS 

absorption  of  the  products  of  inflammation.  Again,  removal  of  the 
obstructing  band  is  followed  by  an  increased  absorption  of  pyogenic 
endotoxins,  the  result  of  bacteriolysis,  and  the  action  of  proteolytic 
ferments,  which  is  likely  to  be  followed  by  unfavorable  secondary  mani- 
festations, especially  in  instances  of  severe  local  infections  which  have 
not  been  freely  incised  (v.  Baumgarten').  On  the  other  hand,  active 
hyperemia  (hot  air  treatment  of  Bier)  increases  absorption  and  has 
a  beneficial  effect  in  cases  of  acute  inflammation. 

The  origin  of  the  bactericidal  substances  contained  in  blood  serum 
is  not  clearly  established.  The  free  complement  contained  in  blood 
is  regarded  by  most  observers  to  be  a  secretion  produced  by  the 
leuxocytes  (Buchner^),  or  the  result  of  their  dissolution  (Metchni- 
koff*^).  This  conception,  however,  has  met  with  keen  opposition,  some 
observers  holding  that  the  leukocytes  are  not  at  all  concerned  in  the 
production  of  complement,  but  ascribe  its  origin  to  the  action  of  other 
cellular  elements  in  the  body.  Bactericidal  substances  (those  which 
resist  the  action  of  heat),  other  than  complement,  believed  to  be  con- 
tained in  leukocytes,  are  not  given  up  by  the  living  cell  {leukocytic 
'protective  substances  of  Peterson'^,  and  the  leukin  of  Schneider^), 
but  are  liberated  when  the  cell  dies. 

Leukocytes,  hy  virtue  of  the  amehic  movements  of  their  protoplasm, 
possess  the  ability  to  engulf  and  assimilate  various  foreign  elements. 
According  to  Metchnikoff 's  conception  of  phagocytosis,  leukocytes  take 
up  the  living  bacteria  and  destroy  them. 

The  observations  of  Buchner*,  v.  Baumgarten^,  and  others  would 
seem  to  show  that  virulent  bacteria  are  not  taken  up  by  the  phago- 
cytes, and  that  their  activity  is  limited  to  those  either  damaged  or 
killed  by  the  action  of  the  bactericidal  substances  contained  in  the 
serum.  It  is  certain  that  bacteria  are  not  immediately  killed  after 
they  are  taken  up  by  the  leukocytes,  and  that  many  remain  alive  and 
unchanged  in  form  for  a  considerable  period  of  time  (gonococci, 
tubercle  and  leprosy  bacilli)  ;  indeed,  anthrax  bacilli  contained  in 
cells  have  been  successfully  cultured  by  Metclniikoff^ 

According  to  Metchnikoff  V  original  conception,  immune  serum  — 
and  to  a  slight  extent  normal  serum  —  contains  substances  that  are 
capable  of  stimulating  leukocytes  into  phagoc3i:ic  action  (stimulins). 

Wright  believes  that  the  so-called  stimulins  do  not  affect  the 
leukocytes,  but  act  upon  the  bacteria,  rendering  the  latter  more 
delectable  for  consumption  by  the  former;  this  substance  he  calls 
opsonin  (prepare  for  meal) .    Most  observers  regard  Wright 's  opsonins 


GENERAL  DISTURBANCES  IN  WOUND  INFECTION      175 

as  identical  with  the  bactericidal  amboceptors,  an  opinion  he  ve- 
hemently contests.  Neufeld'°,  previous  to  Wright,  described  a  sub- 
stance found  in  immune  serum,  similar  to  opsonin,  which  he  called 
bacteriotropin. 

Wright^  has  applied  his  theory  to  the  treatment  of  various  infectious 
diseases.  He  increases  the  opsonins  of  the  patient  by  immunizing  him 
with  moderate  doses  of  killed  autogenous  bacterial  cultures,  with  the 
view  of  increasing  phagocytosis.  The  opsonic  strength  of  the  serum 
of  the  infected  person  is  reduced  in  comparison  to  that  of  the  healthy 
individual,  but  may  be  increased  in  the  former  by  immunization.  The 
proportion  of  opsonin  content  of  the  serum  of  the  patient  as  compared 
to  normal  serum  indicates  the  severity  of  the  pathological  disturbances 
and  the  extent  to  which  this  is  influenced  by  treatment  (opsonic 
index). 

Invading  bacteria  possess  weapons  of  offense  that  tend  to  overcome 
the  defensive  action  of  bactericides ;  phagocytosis  is  lessened  by  the 
presence  of  aggressins  in  inflammatory  exudates;  bacteria  also  de- 
velop an  adventitious  envelope  (possibly  a  thickening  of  the  proper 
membrane)  which  creates  an  adaptability  to  tissue  environment, 
lessening  bactericidal  efficiency,  and  enhancing  the  virulence  of  the 
bacterial  flora  (Gruber  and  Futaki"). 

This  elucidates  the  utility  of  two  phenomena,  the  congregation  of 
leukocytes  at  the  port  of  invasion,  and  their  increase  in  the  blood 
(active  leukocytosis),  the  latter  occurring  in  almost  all  febrile  infec- 
tious diseases  (excluding  t^-phoid,  measles,  and  most  forms  of  malaria), 
and  also  accompan3'ing  the  absorption  of  infectious  substances  origi- 
nating in  purulent  or  putrefactive  foci.  Both  these  phenomena  may 
be  produced  experimentally  by  introducing  into  a  portion  of  the  body, 
or  into  the  blood  stream,  substances  that  exercise  a  provocative  irrita- 
Hon  upon  motile  leukocytes.  This  process  of  positive  chemotaxis 
occurs  in  response  to  the  action  of  necrotic  tissue,  chemical  agents, 
bacterial  poisons,  and  especially  marked  is  the  response  to  bacterio- 
proteins  (an  albuminous  substance  originating  upon  the  death  of 
bacteria)  (Buchner^).  When  bacterial  poisons  provoke  leukocytosis, 
the  leukocytes  present  in  the  inflammatory  focus,  and  those  in  the 
blood  in  increased  numbers  are  of  a  character  capable  of  forming 
bactericidal  substances.  The  failure  of  leukocytosis  in  purulent 
processes  or  in  general  infections  indicates  either  that  the  body  is 
capable  of  overcoming  the  bacteria  and  their  poisons  without  it,  or 


176  INFECTIONS  OF  WOUNDS 

that  the  system  is  so  overwhelmed  that  it  is  incapable  of  marshaling  its 
combative  forces. 

Leukocytosis  may  be  regarded  as  established  when  there  are  more 
than  ten  thousand  of  these  cellular  elements  in  1  cmm.  of  blood  and 
no  lessening  of  erythrocytes.  The  increase  is  confined  to  that  form  of 
leukocyte  which  is  normally  most  abundant  in  the  blood  (65  per  cent 
to  70  per  cent),  and  reaches  its  greatest  proportion  in  response  to 
inflammatory  processes,  namely,  the  polunuclear  neutrophile.  These 
are  characterized  by  the  fact  that  their  protoplasm  will  take  up  only 
neutral  (neither  acid  nor  basic)  stains,  and  that  their  nuclei  overlap, 
are  irregular  in  form —  somewhat  resembling  a  horse  shoe  or  clover 
leaf  —  and  will  readily  take  up  basic  stains.  Pohiiuclear  neutrophiles, 
according  to  Ehrlich,  originate  in  bone  marrow,  though  some  are 
probably  contributed  by  the  lymphatic  system. 

Leukocj^osis  has  diagnostic  significance  (Curschmann^-),  especially 
in  the  recognition  of  deep-seated  purulent  collections.  It  has  had  its 
greatest  field  of  application  in  connection  with  inflammatory  processes 
in  the  appendix  vermiformis.  As  more  or  less  leukocytosis  occurs 
with  the  development  of  all  kinds  of  inflammatory  exudate  (pneu- 
monia, for  instance),  and  frequently  does  not  become  manifest  even 
in  cases  of  extensive  peritoneal  purulent  inflammation,  the  diagnostic 

SIGNIFICANCE  OF  THE  BLOOD  COUNT  MUST  BE  REGARDED  AS  MERELY  COR- 
ROBORATIVE, AND  NOT  DETERMINING,  WHEN  WEIGHED  AGAINST  CLINICAL 
EVIDENCE. 

Bacteria  are  not  the  only  elements  absorbed  from  infected  tissues; 
toxins,  endotoxins,  and  aggressins  also  gain  access  to  the  body  from 
this  source. 

Toxins  are  not  ordinarily  demonstrable  in  the  blood,  for  the  reason 
that  they  are  bound,  as  soon  as  formed,  by  certain  tissue  cells  for 
which  they  possesse  an  active  affinity.  Experimentally,  the  presence 
of  the  toxins  of  diphtheria  and  tetanus  may  be  demonstrated  in  the 
blood  of  animals  when  they  exist  in  large  quantities,  and  then  only 
immediately  before  or  after  death.  For  instance,  when  blood  con- 
taining tetanus  serum  is  brought  in  contact  with  the  normal  cellular 
elements  of  the  central  nervous  s^-stem  of  susceptible  animals  {in 
vitro),  the  cells  bind  the  toxin  and  render  it  harmless;  per  contra, 
when  the  toxin  is  introduced  into  immune  animals  it  remains  free  and 
circulates  in  the  blood. 

The  Side  Chain  Theory  of  Ehrlich. —  Ehrlich  explains  the  binding  of 
toxins  as  follows:  A  toxin  molecule  possesses  a  haptopJwre  and  a  toxo- 


GENERAL  DISTURBANCES  IN  WOUND  INFECTION      177 

phore  group;  the  former,  by  combining  with  the  body  cells,  liberate 
the  latter,  which  then  become  the  actual  toxin  carriers.  Ehrlich  divides 
the  activity  of  a  living  cell  into  a  functionating  nucleus  and  various 
side  f mictions,  or  side  chains  (receptors),  the  latter  being  concerned 
in  assimilating  the  necessary  nutritive  elements  of  the  cells.  In  the 
binding  of  toxins  the  haptophore  group  are  held  fast  by  the  side  chains 
of  certain  cells  possessing  a  chemic  affinity  for  them,  a  phenomenon 
regarding  w^hich  Fisher  says,  *'the  receptors  fit  the  haptophore  toxin 
group  like  the  key  fits  the  lock."  The  cells  of  the  central  nervous 
system  contain  receptors  capable  of  binding  the  toxin  of  tetanus,  which 
explains  the  symptomatology  of  this  disease.  The  seat  of  the  toxin 
binding  cells  in  other  diseases  is  not  known.  Ehrlich 's  side  chain 
theory  also  elucidates  the  perplexing  phenomena  connected  with  the 
formation  of  antitoxins  and  the  process  of  immunization. 

When  an  animal  is  made  immune  against  fatal  doses  of  tetanus 
toxin  by  the  administration  of  gradually  increasing  doses  of  the  same 
poison,  its  blood  serum  is  capable  of  immunizing  other  animals  against 
the  fatal  action  of  the  toxin,  and  renders  them  incapable  of  contract- 
ing the  disease.  Animals,  serum-immunized  in  this  way,  possess 
tetanus  antitoxin  capable  of  binding,  and  rendering  harmless,  tetanus 
toxin.  This  phenomenon,  first  observed  by  Behring  and  Kitasato 
(1890)  in  connection  wath  the  study  of  tetanus,  has  led  to  the  estab- 
lishment, in  the  experimental  world,  of  the  "Behring  Law."     "The 

BLOOD  SERUM  OF  AN  INDIVIDUAL  SPONTANEOUSLY  (RECOVERY  FROM  THE 
disease)  or  artificially  (by  VACCINATION  WITH  LIVING  CULTURES  OB 
BACTERIAL  POISONS)  IMMUNIZED  AGAINST  A  SPECIFIC  INFECTIOUS  DISEASE 
IS  CAPABLE  OF  TRANSFERRING  THIS  IMMUNITY  TO  OTHERS  WHO  ARE 
SUSCEPTIBLE  TO  THE  SAME  DISEASE. ' ' 

Immunity  resulting  from  the  administration  of  gradually  increas- 
ing doses  of  toxin,  and  the  consequent  formation  of  antibod}^,  is  called 
active  inn)iunitij.  The  term  passive  'immunitij  is  employed  when 
immunity  is  created  b}^  the  injection  of  the  blood  serum  of  an  already 
immunized  animal.  The  former  (active  immunity)  is  similar  to  that 
which  follows  recovery  from  infection,  i.  e.,  acquired  or  earned  immun- 
ity. Diphtheria  immunity  is  similar  to  that  of  tetanus,  that  is,  it  is 
dependent  upon  the  creation  of  antitoxin;  in  other  infectious  diseases 
the  antibody  is  not  operative  against  the  toxins,  hut  acts  against  the 
aggressors  themselves.  The  individual  may  also  be  immunized  against 
albuminous  vegetable  poisons  such  as  ricin,  ahrin  (Ehrlich),  and  sJiake 
venom  (Calmetti),  but  not  against  tbf^  alkaloid  poisons. 


178  INFECTIONS  OF  WOUNDS 

In  the  process  of  immunization  (also  in  natural  immunity),  accord- 
ing to  the  side  chain  theory,  the  toxins  are  bound  by  the  cellular 
elements  of  organs  susceptible  to  them  (in  tetanus,  the  central  nervous 
system),  that  is,  their  side  chains  or  receptors  take  up  the  haptophore 
group  of  the  toxin  and  anchor  it,  provided  the  poison  is  not  present  in 
sufficient  quantity  to  kill  the  host,  an  outcome  obviated  by  limiting 
the  initial  dosage  and  gradually  increasing  it  as  tolerance  develops. 
As  the  receptors  concerned  in  binding  the  toxin  are  produced  in  a 
greater  quantity  than  is  necessary  to  attain  this  end  (just  as  every 
defect  in  the  tissues  is  followed  by  overproduction),  and  as  the  cell 
retains  only  the  side  chains  (receptors)  essential  to  the  exercise  of  its 
function  in  this  connection,  the  excess  is  cast  off  and  taken  up  b}^  the 
blood  stream;  consequently  the  blood  also  contains  free  receptors 
capable  of  binding  toxins.     While  the  side  chains  retained  in  the 

CELLS  ANCHOR  A  CERTAIN  PROPORTION  OF  A  GIVEN  TOXIN,  THE  FREE 
RECEPTORS  BIND  THOSE  CIRCULATING  IN  THE  BLOOD,  THUS  RENDERING  THE 
POISON  INCAPABLE  OF  DAMAGING  FURTHER  THE  VARIOUS  PARTS,  ORGANS, 
AND  TISSUES  OF  THE  BODY.  In  OTHER  "WORDS,  THE  EXCESS  OF  RECEPTORS 
OAST  OFF  BY  THE  CELLS  AND  NOW  CONTAINED  IN  THE  BLOOD  CONSTITUTES 
ITS  ANTITOXIN,  THE  ACTIVE  PRINCIPLE  OF  ALL  IMMUNE  SERA, 

Antitoxic  serum,  however,  neutralizes  only  a  given  toxin;  the  bac- 
teria themselves  retain  their  vitality  and  are  ultimately  destroj^ed  by 
the  phagocytes,  the  natural  resistance  of  the  host,  and,  perhaps,  also 
by  the  action  of  the  saprophytes. 

Immunization  by  the  formation  of  antitoxin,  in  the  manner  de- 
scribed, OCCURS  ONLY  IN  INFECTIONS  IN  WHICH  A  TOXIN  IS  THE  DISTURB- 
ING FACTOR.  In  OTHER  INFECTIONS  THE  BLOOD  SERUM  OF  PERSONS  WHO 
HAVE  RECOVERED  FROM  A  GIVEN  DISEASE,  AND  THAT  OF  ARTIFICIALLY 
immunized  animals,  CONTAINS  A  SPECIFIC  BACTERICIDAL  ANTIBODY  THAT 
ACTS  UPON  THE  AGGRESSORS   ( BACTERIA)   WITHOUT  BINDING  THEIR  TOXINS 

(cholera,  t^'phoid,  pest,  and  probably  certain  pyogenic  aggressors). 
The  precise  manner  in  which  the  toxins  liberated  upon  the  dissolution 
of  bacteria  {eiidotoxiyis)  are  counteracted  by  the  host  is  not  clear.  R. 
Pfeiffer^^,  Friedberger^*,  and  others  assume  that  they  are  converted 
into  harmless  substances  by  the  action  of  certain  specific  ferments 
(immune  hodies  and  complement)  contained  in  the  blood.  In  any 
case,  it  is  certain  that  anti-endotoxins  are  not  formed. 

Bactericidal  immune  serum  contains  a  specific  immunizing  hodjj 
which  is  identical  with  the  amboceptor  previously  described  (p.  172) 
as  existing  in  normal  serum,  but  it  is  greatly  increased  in  quantity  by 


GENERAL  DISTURBANCES  IN  WOUND  INFECTION      179 

the  process  of  immunization.  This  immunizing  body  is  bound,  on  the 
one  hand,  with  the  bacteria,  and,  on  the  other,  combines  with  the 
complement  (alexin)  of  the  normal  blood  serum  (Ehrlich)  which 
thus  is  made  capable  of  digesting  the  bacteria.  A  small  quantity  of 
immunized  serum  injected  into  a  normal  animal  is  sufficient  to  pro- 
tect it  against  infection,  as  the  bacteria  gaining  entrance  into  the 
body  are  promptly  dissolved.  When  immunized  serum  is  withdrawn 
from  the  body,  it  soon  (a  few  days)  loses  its  bactericidal  capacity  as 
its  very  unstable  complement  rapidly  decomposes.  It  may,  however, 
be  reactivated  by  the  addition  of  fresh  serum  from  a  normal  animal, 
which  furnishes  new  complement  to  the  immunizing  body  still  surviv- 
ing (Metchnikoff^). 

H.  Pfeiffer^^  combats  the  notion  that  immunizing  bodies  are  merely 
'passive  hi  their  action.  He  believes  that  they  possess  the  character- 
istics of  a  proferment,  and  when  combined  with  the  complement,  act 
in  a  manner  similar  to  that  of  enterokinase  and  pancreatic  secretion 
of  the  intestinal  canal,  v.  Baumgarten^®  does  not  accept  the  theory  of 
fermentative  solution  of  bacteria,  and  explains  bacteriolysis  on  the 
basis  of  osmotic  disturbance,  i.  e.,  the  binding  of  the  immunizing  body 
with  the  complement  causes  an  increase  in  the  osmotic  pressure  of  the 
bacterial  protoplasm,  and  a  consequent  expulsion  of  their  soluble 
albumin  content.  The  process  of  development  of  specific  immunizing 
bodies  like  the  antitoxins,  is  explainable  in  accordance  with  the  theory 
of  Ehrlich;  the  toxic  constituents  of  bacteria  entering  the  body  are 
partially  dissolved  by  normal  bactericidal  action,  the  rest  are  bound 
by  the  side  chains  (receptors)  of  the  various  cellular  elements  having 
an  affinity  for  them.     These  receptors,  being  produced  in  excess  by 

THE  CELLS,  CIRCULATE  IN  THE  BLOOD,  AND,  BY  VIRTUE  OF  THEIR  ABILITY 
TO  BIND  THE  SPECIFIC  TOXIC  CONSTITUENTS  OF  BACTERIA,  FORM  THE 
IMMUNIZING  BODY  W^HICH  IN  TURN  MAKES  POSSIBLE  THE  DIGESTIVE  ACTION 

OF  THE  COMPLEMENT.  The  proces«  of  development  of  immunizing 
bodies  is  not  known  in  all  infectious  diseases.  The  cells  possessing  a 
binding  capacity  (source  of  receptors)  for  cholera  and  typhoid  are 
those  of  hone  marrow,  the  spleen,  and  the  lymphatic  nodes  (Wasser- 
mann^'^).  Wassermann  and  Heim^^  consider  that  this  function  —  as 
applied  to  pneumonia  —  resides  in  the  cells  of  the  bone  marrow  and 
the  general  muscular  system.  These  cellular  elements  must  of  course 
be  regarded  as  the  source  from  which  the  immunizing  bodies  originate. 
The  action  of  immunized  sera  is  not  limited  to  the  formation  of 
specific  bodies  which,  together  with  complements,  dissolve  bacteria : 


180  INFECTIONS  OF  W0UNT3S 

in  addition  to  this,  man}^  immune  sera,  or  at  least  the  blood  of  persons 
who  have  recovered  from  infections,  contain  substances  that  cause 
coalescence  {agglutination)  of  the  aggressors  (bacteria).  These  sub- 
stances are  called  agglutinins,  and,  when  concerned  in  agglutinating 
specific  bacteria,  are  called  specific  agglutinins.  They  are  present  in 
the  blood  of  persons  infected  with  tj-phoid  (Widal)  and  tuberculosis 
bacilli  (Koch)  and  in  strepto-  and  staphylococcus  immune  serum. 
'  Experimentally,  immunizing  bodies  —  called  cytohjsins  —  that  de- 
stroy the  cells  of  other  species  may  be  developed  in  the  blood  (red  and 
white  blood  corpuscles,  epithelial  cells,  and  spermatozoa).  In  some 
instances  the  immunized  sera  dissolve  the  foreign  cells;  in  others, 
they  agglutinate  them.  The  administration  of  hemoli/tic  (dissolving 
red  blood  corpuscles)  and  leukotoxic  sera  (dissolving  leukocytes)  is 
followed  by  a  fatal  outcome.  The  administration  of  foreign  proteins 
(animal  and  vegetable)  causes  the  development  of  antibodies 
{precipitins)  which  results  in  the  precipitation  of  the  former.  This 
permits  of.  the  differentiation  of  human  from  animal  protein,  a  fact 
of  forensic  significance  (Wassermann^^). 

The  term  antigen  is  applied  to  all  substances  that  provoke  the  forma- 
tion of  antibodies,  i.  e.,  all  bacterial,  cellular,  and  protein  substances 
operative  in  the  immunizing  process  (baeteriolysins,  agglutinins, 
opsonins,  cytolysins,  precipitins,  etc.). 

The  poisonous  substances  absorbed  by  the  blood  are  the  toxins;  the 
endotoxins  (bacterial  poisons),  which  are,  perhaps,  most  largely  devel- 
oped by  pyogenic  bacteria ;  the  aggressins,  which  originate  from  the 
bacteria  in  inflammatory  exudates  and  protect  them  against  the  defen- 
sive action  of  the  leukocytes;  and  an  anti-aggressin  generating  sub- 
stance which  tends  to  balance  or  overcome  the  evil  influence  of  the 
aggressins.  It  is  highly  probable  that  to  these  may  be  added  other 
toxic  substances,  developed  by  the  activities  of  bacteria,  which  are  not 
specific  in  character,  such  as  the  anaphylatoxin  of  Friedberger.^* 

Excluding  the  formation  of  protective  substances,  tlie  action  of 
bacterial  poisons  upon  the  hody  is  destructive.  Their  pernicious  effect 
varies  with  their  method  of  attack,  their  character,  and  their  quan- 
tity. This  is  illustrated  in  tetanus,  the  clinical  manifestations  of 
which  find"  expression  in  disturbances  of  the  central  nervous  system; 
and  in  diphtheria  Mhich  is  so  frequently  followed  by  toxic  neuritis 
and  paralysis.  Severe  cerebral  disturbances  are  surely  due  to  the 
presence  of  toxic  substances  in  the  blood,  and  invariably  accompany 
virulent    bacterial    wound    infection.     The    occurrence    of    myelitis, 


GENERAL  DISTURBANCES  IN  WOUND  INFECTION      181 

neuritis,  neuralgia,  neuroses,  gastric  disturhances,  and  albuminuria 
may  be  ascribed  to  the  same  cause.  Many  toxins,  especially  those  of 
tetanus  bacilli,  staphylo-  and  streptococci,  and  the  bacillus  pyocyaneus, 
dissolve  red  hlood  corpuscles,  which  accounts  for  the  increased  urobilin 
in  the  urine  in  cases  of  infection  with  these  organisms.  To  this  may 
be  added  the  general  emaciation  and  anemia  of  chronic  suppurative 
inflammatory  processes  {osteomyelitis,  general  infections),  and  the 
parenchymatous  and  amyloid  degeneration  of  organs  (heart,  liver, 
kidneys,  etc.),  consequent  to  prolonged  toxic  disturbances  (tubercu- 
losis, actinomycosis,  syphilis,  etc.). 


BIBLIOGRAPHY 

1.  ScHiMMELBUSCH.    Fortschr.  d.  Med.  Bd.  13,  1895, 

2.  NoTZEL.    Beitr.  z.  klin.  Cliir.  Bd.  74,  1911. 

3.  BucHXER.    Miiucli.  med.  "Wocli.,  1891. 

4.  MORGEXROTH.    Zentrbl.  f.  Bakt.  Grig-.  Bd.  59, 1911. 

5.  V.  Baumgartex^.    Miinch.  med.  Woeh.,  1908. 

6.  Metchxikoff.     In  Kolle-Wassermann  Handb.  d.  path.  Mieroorg.   (2d 

ed.)  Bd.  ii,  1912,  with  lit. 

7.  Peterson.    Zentrbl.  f.  Bakt.  Orig.  39, 1905;  also  42, 1906  Grig. 

8.  Schneider.    Arch.  f.  Ilyg.  Bd.  70,  1909. 

9.  Wright.    Stud,  iiber  Immun.  etc.,  Jena,  1909. 

10.  Neufeld.     Same  as  No.  6. 

11.  Gruber  and  Futaki.    Miinch  med.  Woch.,  1907. 

12.  CuRSCHiiAxx\    Miinch.  med.  Woch.,  1901. 

13.  R.  Pfeiffer.     Weichards  Jahresbr.  a.  d.  Immun.  Bd.  ii,  1911,  with  lit. 

14.  Friedberger.     Fortsch.  d.  Deutsch.  klin.  Bd.  ii,  1911,  with  lit. 

15.  H.  Pfeiffer.    Zeitschr.  f.  Immun.  Bd.  10,  1911. 

16.  V.  Baumgartex".     Lehrb.  d.  path.  Mieroorg.,  Leij^zig,  1911. 

17.  Wassermaxx.     Deutsch.  med.  Woch.,  1907. 

18.  Heim.    :\Iiinch.  med.  Woch.,  1909. 

19.  Wassermaxx.     Samml.  klin.  Vort.  N.  F.  No.  331, 1902,  Leipzig. 


CHAPTER  IV 

HYPEESUSCEPTIBILITY   AND  ANAPHYLAXIS 

The  experimental  and  therapeutic  use  of  immunizing  sera  is  at 
times  attended  with  peculiar  pathological  disturbances,  which  v. 
Behring  calls  hypersusceptihility.  In  1893  v.  Behring,  while  immu- 
nizing animals  against  diphtheria,  observed  that,  after  repeated,  and 
at  times  only  a  few,  injections  of  toxin  (despite  a  marked  increase  in 
the  antitoxin  content  of  the  blood),  the  animal  gave  evidence  of  severe 
toxemia;  that  is,  i?istead  of  immunity  being  established,  a  specific 
increase  in  susceptihility  to  the  special  toxin  employed  was  created. 
It  was  assumed  that  in  these  instances  the  toxin  was  not  neutralized 
by  the  free  antitoxin  in  the  blood,  but  was  bound  by  the  tissue  cells 
of  certain  vital  organs,  the  receptors  of  which  (so-called  sessile 
receptors,  i.  e.,  the  increased  but  not  yet  liberated  side  chains)  pos- 
sessed an  increased  binding  avidity  for  them  (v.  Behring,  Wasser- 
mann^),  an  assumption  strongly  contested  by  Friedberger^  and  others. 

Hypersusccptihility  is,  however,  not  limited  to  immunizing  sera. 
Eicliet  found  that  in  some  instances  the  administration  of  certain 
protein  poisons  (eel  serum,  actinien  toxin,  etc.)  was  not  followed  by 
antitoxic  immunity,  but  on  the  contrary,  seemed  to  establish  a  Jiyper- 
susceptihility  as  regards  these  poisons.  This  condition  of  nondefense 
he  called  anaphylaxis  (better,  aphylaxis,  Lexer^)  in  contradistinction 
to  prophylaxis.  The  term  anaphylaxis  is  used  to  distinguish  hyper- 
susceptibility  to  all  protein  substances  (animal,  vegetable,  toxic  and 
nontoxic  albuminins,  normal  serum  of  different  species,  and  immunized 
sera)  from  that  pertaining  •  to  hypersusceptibility  to  chemical 
substances. 

The  mechanism  of  anaphylaxis  is  not  clearly  understood.  Accord- 
ing to  Friedberger^,  anaphylaxis  is  the  hypersusceptibility  of  the 
ORGANISM  TO  THE  PARENTERAL  (uot  brought  in  contact  with  digestive 
organs)  introduction  of  foreign  proteins.  A  single  parenteral 
ADMINISTRATION  (by  injection)  of  a  subtoxic  dose  results,  after  a  cer- 
tain period  of  time   {period  of  incubation) ,  in  the  development  of 

182 


HYPERSUSCEPTIBILITY  AND  ANAPHYLAXIS        183 

specific  antibodies.  This  first  injection  is  called  the  sensitizer  or 
preparer;  the  antibody  is  called  the  anaphylactic  reaction  body  or  the 
anaphylactic  immunizing  body.  AYhen  (after  ten  or  more  days)  the 
second  injection  (reinject ion)  of  the  same  protein  is  made,  the  reac- 
tion body,  together  with  the  complement,  splits  it  into  actively  poison- 
ous products  "vvhich,  in  accord  with  the  dosage,  causes  severe  shock 
accompanied  b}'  a  sudden  drop  in  temperature  {anaphylactic  temper- 
ature drop),  in  some  instances  by  hyperpyrexia,  ending,  not  infre- 
quently, in  death.  Less  severe  anaphylaxis  is  attended  with  more  or 
less  dyspnea,  falling  blood  pressure,  muscular  cramp,  and  acute 
bronchial  distention  due  to  contracture  of  the  bronchial  muscle  fibers. 
This  is  called  active  anaphylaxis.  If  an  animal  survive  the  reaction 
consequent  to  reinjection,  a  third  injection  (given  soon  after  the 
second)  finds  it  immune  to  the  same  protein  bod}',  i.  e.,  a  temporary 
anti-anaphylaxis  has  occurred.  This  condition  of  anti-anaphylaxis  may 
be  produced  by  injecting  a  normal  animal  with  the  serum  of  one 
which  has  previously  survived  an  active  anaphjdaxis.  This  is  called 
passive  anaphylaxis.  The  poisonous  protein  product  responsible  for 
anaphylaxis  has  been  produced  by  Friedberger^  {in  vitro)  by  causing 
first,  protein  (as  an  antigen  called  here  anaphylactogen)  ;  second, 
antibody  {anaphylactic  reaction  body,  similar  to  protein  antibody  or 
precipitin)  ;  and  third,  complement  to  act  upon  each  other.     By  com- 

mxiXG  THE  PROTEIN  WITH  THE  PROTEIN  ANTIBODY,  THE  COMPLEMENT  IS 
BOUND,   THUS  SPLITTING  OFF  THE   TOXIC   SUBSTAX'CE   WHICH   RESEMBLES 

PEPTONE  AND  IS  CALLED  ANAPHYLAToxiN.  The  actiou  of  the  substance 
created  in  this  way  is  not  specific.  Its  administration  in  normal 
animals  is,  however,  followed  by  the  typical  s^miptomatology  of  ana- 
phylaxis. The  precise  organic  involvement  in  cases  of  anaphylaxis 
poisoning  is  not  known. 

Eosenau*  defines  anaphylaxis  as  ^'a  condition  of  U)iusual  or  exag- 
gerated susceptibility  of  the  organism  to  foreign  proteins/'  which, 
according  to  Freidberger-  would  not  seem  to  cover  the  ground. 
Friedberger's-  conception  (not  yet  fully  accepted)  may  be  stated  as 
follows:  Bacterial  poisons  are  capable  of  acting  as  anaphylactogens 
both  in  antibacterial  and  in  antitoxic  immunit}'.  In  bacterial  infec- 
tion attended  with  the  presence  of  antitoxic  or  bactericidal  bodies,  the 
anaphylactogenic  reaction  body  is  as  actively  operative  as  precipitin 
is  against  protein,  and  is  a  cytolytic  amboceptor  against  foreign  cells. 

If  in  THE  COURSE  OF  INFECTION,  AGAINST  WHICH  IMMUNIZING  BODIES 
HAVE   ALREADY  BEEN   FORMED,   THE   AREA   OF   INFLAMMATION   FURNISHES 


184  INFECTIONS  OF  WOUNDS 

THE  BLOOD  WITH  ADDITIONAL  BACTERIAL  TOXINS,  THESE  COMBINE  WITH 
THE  IMMUNIZING  BODIES  AND  COMPLEMENT,  THUS  FORMING  ANAPHY- 
LACTIC TOXIN,  This  may  exjDlain  the  action  of  many  bacteria  (strepto- 
and  pneumococci,  anthrax  bacilli,  etc.),  the  specific  toxins  and  endo- 
toxins of  which  have  not  3'et  been  recognized  (Lexer^), 

Anaphylaxis  accounts  for  the  hu per s usee piibility  not  infrequently 
attendant  upon  the  administration  of  therapeutic  sera:  In  some 
instances  a  single  injection  of  diphtheria  serum  is  at  once  followed  by 
evidence  of  poisoning;  suffocation,  cyanosis,  subnormal  temperature, 
and  death;  in  others  (about  10  per  cent),  the  manifestations,  consist- 
ing of  fever,  exanthema,  and  glandular  and  arthritic  enlargements, 
are  less  severe  and  do  not  appear  until  after  a  period  of  incubation  of 
from  seven  to  ten  days  has  elapsed.  AVhen,  however,  anaphylaxis 
follows  a  second  injection,  it  occurs  immediately  after  the  adminis- 
tration of  the  serum,  and  is  frequently  accompanied  by  a  local  reaction 
in  the  form  of  an  inflammatory  exudate  {serum  reaction  of  v.  Pirquet 
and  Schick^). 

For  the  purpose  of  preventing  anaphylaxis  in  the  use  of  therapeutic 
sera,  it  is  recommended  that  those  of  low  protein  content  be  employed. 
It  is  also  regarded  wise  in  sequential  administration  to  use  the  sera  of 
several  animals;  for  instance,  when  a  prophylactic  injection  is  made 
against  diphtheria,  if  a  second  (curative)  injection  is  necessary,  the 
serum  should  be  taken  from  an  animal  other  than  the  one  from  which 
the  first  was  obtained.  Friedberger  and  Mita-  obviated  anaphylaxis 
as  follows:  By  means  of  a  special  apparatus,  the  therapeutic  serum 
was  so  slowly  flowed  into  a  vein  that  only  a  small  portion  of  anaphy- 
lacogen  entered  the  blood,  and  the  binding  of  anaphylactogenic  anti- 
body at  no  time  allowed  of  the  binding  of  a  poisonous  or  fatal  quantity 
of  anaphylatoxin ;  in  this  way  a  degree  of  anti-anaphylaxis,  permit- 
ting of  the  safe  introduction  of  great  quantities  (ten  times  the  amount 
of  foreign  protein  usually  considered  a  fatal  dose)  of  serum  was 
obtained.  Besredka®  advises  that,  before  the  second  injection  is  made, 
small  quantities  of  serum  be  subcutaneously  administered.  Experi- 
mentally, Langer^  seems  to  have  shown  that  repeated  ingestion  of 
small  doses  of  sodium  chlorid  acted  as  a  protective  influence  in  this 
connection.  It  must  be  borne  in  mind  that  anaphylaxis  occurs  only 
when  an  interval  of  from  three  to  six  weeks  is  allowed  to  elapse 
between  injections ;  never,  if  the  intervals  are  from  one  to  seven  days. 
The  menacing  symptoms  following  transfusion  of  lamb's  blood,  and 


HYPERSUSCEPTIBILITY  AND  ANAPHYLAXIS        185 

even  the  blood  of  the  same  species  of  animal,  are  explainable  on  the 
basis  of  anaphylaxis. 

Anaphylaxis  explains  the  tuhercului  lujpersusceptibilitij  on  part  of 
the  tuberculous  host  and,  perhaps,  also  the  manifestation  following 
the  escape  of  the  contents  of  echinococcus  cysts  into  the  peritoneum 
(after  puncture). 

Iodoform  idiosyncrasy  and  death  following  burns  may  also  be 
explained  in  this  way:  As  regards  the  former,  the  binding  of  iodin 
with  foreign  protein  acts  as  an  anaphylactogen ;  in  the  latter,  necrotic 
tissue  forms  a  similar  combination. 

To  this  may  be  added,  that  the  idiosyncrasies  shown  for  certain 
articles  of  diet  in  puerperal  eclampsia,  for  siiblimate,  and  hay  fever 
(pollen  protein  intoxication)  may,  perhaps,  be  elucidated  on  the  basis 
of  anaphylactic  phenomena ;  also,  the  bearing  this  has  on  the  behavior 
of  blood  in  its  forensic  application  must  be  taken  into  account. 

Finally,  anaphylaxis  has  an  important  influence  upon  the  produc- 
tion of  febrile  disturbances  consequent  to  infectious  diseases  and  the 
absorption  of  aseptic  tissue  products. 


BIBLIOGRAPHY 

1.  Wassermanx.     Deutsch.  med.  "Wocb.,  1907. 

2.  Friedberger.     Vehr.  d.  med.  Kong.,  1913. 

3.  Lexer.    Allg.  CMr.  Bd.  i,  Stuttgart,  1914. 

4.  RosENAU.     in  Kolmer's  Inf.  Immun.  etc.,  N.  Y.,  1915. 

5.  V.  PiRQUET  and  Schick.     Same  as  No.  4. 

6.  Besredka.     Same  as  No.  4. 

7.  Langer,     Miinch.  med.  Woch.,  1912, 


CHAPTER  V 

FEVER 

Clinically,  the  reactive  processes  provoked  by  bacterial  and  toxic 
invasion  find  expression  in  a  number  of  manifestations  which  may  be 
grouped  under  the  general  head  of  fever  or  pyrexia. 

Rise  of  body  temperature  is  the  chief  symptom  of  fever,  increasing 
from  98.2°F.  (36.8°C.)  to  104°F.  (40°C.),  and  more  in  accord  with 
the  severity  of  the  causative  factor ;  other  sjTuptoms  are  disturbances 
of  the  digestive  tract  (vomiting),  the  circulation  (increased  pulse 
rate),  and  of  the  sensorium  (delirium  and  unconsciousness)  ;  also, 
cephalalgia  and  irritability.  These  manifestations  vary  in  intensity 
with  the  rise  and  fall  of  the  fever,  though  they  may  be  regarded  as 
due  to  the  cause  of,  rather  than  the  result  of,  the  fever  itself. 

The  mechanism  of  pyrexia  may  be  described  as  a  disturbance  of 
balance  between  heat  production  and  its  rate  of  radiation. 
Normally,  the  heat  given  off  from  the  body  by  skin  radiation  and 
evaporation  of  water  from  the  lungs  and  skin  is  equal  to  that  devel- 
oped in  the  process  of  oxidation  within  the  body  (chiefly  the  muscular 
system).  In  the  presence  of  fever,  heat  production  is  increased,  and 
the  avenues  of  egress  do  not  suffice  for  the  purpose  of  radiation. 
P;y'Texia  is  attended  by  exaggerated  chemic  metabolism  and  caloric 
consumption,  as  shown  by  the  increase  of  expired  carbon  dioxid  (Lieber- 
meister,  v.  Leyden),  of  inspired  oxygen  (Regnard,  Zuntz),  and  by  the 
increase  of  nitrogen  content  of  the  urine,  due  to  an  accelerated  con- 
sumption of  protein.  Normally,  increased  metabolism,  such  as  attends 
active  muscular  effort,  does  not  provoke  fever  because  the  increased 
heat  production  is  balanced  by  increased  radiation;  when,  however, 
fever  is  present  the  latter  is  not  capable  of  activities  commensurate 
with  the  former,  and  a  heat  stasis  occurs ;  indeed,  in  some  instances 
of  infection,  heat  radiation  falls  below  the  normal  (Traube^). 

The  causative  factor  in  fevers  increases  consumption  of  the  body 
itself,  together  with  its  protein,  glycogen,  etc.,  these  forming  the  only 
fuel  in  pyrexia,  as  they  do  under  normal  conditions  (KrehP). 

186 


FEVER  187 


The  sudden  onset  of  fever  (stadium  inerementi)  is  frequently 
attended  by  a  chill;  here,  again,  radiation  is  not  equivalent  to  heat 
development,  because  the  peripheral  capillaries  are  in  a  condition  of 
tonic  contracture,  due  to  the  action  of  the  cause  of  the  fever  upon  the 
vasomotor  centers,  and,  when  this  provokes  reflex  action  upon  the 
entire  body,  rigor  occurs.  During  heat  stasis  (fastigium),  which 
follows  in  from  one  to  two  hours  after  the  initial  chill,  the  skin  is  hot, 
dry,  and  reddened.  Heat  radiation  is  not  sufficient  to  balance  heat 
production. 

Lessening  of  ike  pyrexia  (stadium  decrement i)  is  frequently 
attended  with  sweating  and  proportionate  decrease  in  the  other  con- 
stitutional disturbances.  Heat  production  lessens  and  radiation  is 
increased.  If,  during  the  febrile  disturbances,  the  resistance  of  the 
body  is  overcome,  apj-rexia  also  occurs,  heat  production  ceases,  and 
the  consequent  heart  failure  (collapse)  often  results  fatally. 

In  surgical  diseases  the  slgnifi.cance  of  fever  pertains  to  its  expres- 
sion, i.  e.,  degree  of  temperature,  time  of  appearance,  whether  con- 
stant, remittent,  or  intermittent ;  often  presenting  a  picture  quite  in 
accord  with  the  character  of  the  process  provoking  it,  indicating  the 
condition  of  the  wound,  the  development  of  inflammation  (or  its 
absence),  and  the  collection  of  inflammator}^  products.  "When  the 
accumulation  of  inflammatory  products  gives  rise  to  fever,  their  expul- 
sion is  immediately  followed  by  lessening  of  pj'rexia,  which,  of  course, 
makes  the  degree  of  fever  a  valuable  diagnostic  and  prognostic  guide 
in  this  connection. 

The  cause  of  fever  is  believed  to  be  the  presence,  in  the  circulation, 
of  proteins  which  have  undergone  decomposition  and  by  their  toxic 
action  cause  an  additional  decomposition  of  certain  protein  constitu- 
ents of  the  body.  In  this  connection  two  classes  of  proteins  come 
under  consideration:  The  foreign,  and  those  liberated  upon  the 
decomposition  of  the  cellular  elements  of  the  host  (autoproteins). 
The  foreign  proteins  of  practical  import  are:  Animal  sera  (normal 
or  immunized),  bacterial  toxins,  substances  liberated  by  bacteria  upon 
their  death,  and  toxic  albumins  (snake  venom)  ;  those  which  are  the 
product  of  decomposed  cellular  elements  (such  as  hemoglobin,  nuclein, 
and  the  albumoses)  originating  in  hematomata  in  contused  tissues, 
and  in  the  exudates  of  inflammatory  areas,  are  the  most  important. 
That  is  to  say,  fever  is  due  not  only  to  the  presence  of  decomposed 
foreign  proteins,  but  also  is  caused  by  the  absorption  of  proteins  that 
normally  exist  in  the  body  and  become  toxic  as  the  result  of  their 


188  INFECTIONS  OF  "WOUNDS 

chemic  decomposition.  In  addition  to  tliis,  febrile  disturbances  result 
from  the  development  in  the  blood  of  proteins  foreign  to  it,  i.  e.,  toxins 
and  chemic  substances  that  dissolve  blood  cells.  It  was  believed  that 
certain  ferments  (fibrin  ferment  of  Schmidt,  pepsin,  and  pancreatin) 
acted  in  a  similar  manner ;  this  however,  would  seem  to  be  disproved 
by  Schnitzler,  Ewald,^  and  others. 

The  decomposition  (splitting)  of  proteins,  together  with  the  action 
of  complement,  results  in  the  formation  of  a  specific  antibody  (pre- 
cipitin, antitoxin,  bacteriolytic,  and  cytolytic  immunizing  body). 
This  defensive  action  is,  in  all  instances,  attended  hy  pyrexia,  which 
explains  the  occurrence  of  fever  when  pathogenic  aggressors  and  their 
toxins  invade  the  circulation;  and  also  elucidates  the  influence  that 
active  and  passive  immunization  exercises  upon  its  manifestations 
(character,  duration,  etc.).  The  appearance  of  antibodies  (protective 
substances  of  all  kinds)  and  the  lessening  of  fever  are  coincident;  for 
instance,  the  drop  of  fever  in  pneumonia  occurs  simultaneously  with 
the  development  of  antibodies  in  the  blood ;  and  the  injection  of  anti- 
toxin in  diphtheria  is  promptly  followed  by  its  disappearance.  How- 
ever, it  is  difficult  to  entirel}^  explain  the  variations  in  type  of  pyrexia, 
by  assuming  the  existence  of  a  perfect  accord  between  fever  and  the 
domination  of  either  toxic  or  antitoxic  phenomena;  especially  when 
it  is  borne  in  mind  that  the  fever  of  infections  may  end  in  either  crisis 
(suddenly),  or  lysis  (gradually),  and  may  be  continued,  remittent, 
or  intermittent  (rarely  the  last)  in  character.  That  fever  occurs  in 
response  to  very  complex  phenomena  is  shown  by  the  recent  develop- 
ments evolved  from  the  study  of  anaphylaxis.  These  studies  show 
that  the  parenteral  introduction  of  all  foreign  proteins  is  followed  by 
pyrogenic  disturbances  (rise  or  fall)  in  accord  with  the  severity  of  the 
anaphylaxis,  i.  e.,  in  accord  with  the  quantity  of  protein  substances 
split  into  poisonous  bodies  (anaphylatoxins)  ;  apjTCxia,  fever,  or 
death  occurs. 

The  absorption  of  pathogenic  aggressors  and  their  toxins  is  respon- 
sible for  the  presence  of  parenteral  proteins  in  the  body  which  create 
hypersusceptibility  during  the  stage  of  incubation ;  a  second  more  or 
less  gradual  invasion  obviates  the  occurrence  of  anaphylactic  reaction. 

The  decline  of  temperature  following  the  liberation  of  local  collec- 
tions of  pus,  of  inflammatory  exudate,  or  the  amputation  of  a  gan- 
grenous limb  indicates  that  bacterial  poisons  and  putrid  substances 
are  no  longer  being  absorbed ;  a  subsequent  rise  of  temperature  justi- 
fies the  conclusion  that  the  invasion  of  the  pyogenic  process  is  resumed, 


FEVER  189 

or  that  drainage  of  its  end  products  is  partially  obstructed.  If  free 
incision  or  amputation  does  not  suffice  to  control  the  infection,  fever 
persists  until  death,  hecause  toxins  are  heing  formed  more  rapidly 
than  are  the  protective  antibodies. 

In  overwhelming  fatal  infections,  fever  may  be  absent;  that  is,  the 
virulence  of  the  aggressors  or  the  resistance  of  the  host  may  be  such 
as  to  preclude  the  occurrence  of  reaction,  just  as  the  experimental 
introduction  of  fatal  quantities  of  bacterial  poisons  is  attended  with 
absence  of  fever,  subnormal  temperature,  and  rapid  collapse.     From 

THIS  IT  MAY  BE  SEEN  THAT  FE\TCR  INDICATES  NOT  ONLY  THE  ONSET  AND 
EXTENSION  OF  INFECTION,  BUT  IS  ALSO  AN  INDEX  AS  TO  THE  RESISTANCE 
OF  THE  HOST  AND  THE  EFFECTIVENESS  OF  MEASURES  OF  RELIEF. 

Although  pyrexia  of  itself  may  not  be  regarded  as  serving  a  useful 
purpose  in  combating  infection,  it  is  certain  that  its  reduction  by  the 
administration  of  chemical  antipyretics  does  not,  and,  therefore, 
should  be  avoided. 

It  is  not  improbable  that  their  administration  disturbs  the  immunity 
reaction,  and  interferes  with  the  prompt  and  efficient  formation  of 
specific  antibodies.  Not  the  least  objection  to  the  artificial  reduction 
of  fever  lies  in  the  loss  of  a  valuable  diagnostic  and  therapeutic  guide, 
Ihe  character  and  persistence  of  fever  frequently  indicating  to  the 
surgeon  the  condition  of  the  wound  and  the  method  of  procedure  to 
be  employed. 

Fever  not  due  to  infectimi  —  aseptic  and  noninfectious  fever  — 
attends  the  solution  of  continuity  of  tissue,  subcutaneous  contusions, 
fractures,  hemorrhagic  infiltrations  (vascular  sarcomata),  and  injury 
to  certain  areas  in  the  brain.  This  fever  is  differentiated  clinically 
from  that  of  infection  by  the  absence  of  chill  and  other  systemic  dis-. 
turbances,  including  the  pulse  rate  which  is  rarely  markedly  acceler- 
ated. The  temperature  does  not,  as  a  rule,  rise  above  100. 5°F. 
(38.5°C.). 

Aseptic  fever  is  due  to  the  absorption  of  pyrogenic  substances 
formed  in  areas  of  extravasation,  or  where  necrosis  of  tissue  has 
occurred.  Alexander  Schmidt,  x.  Bergmann,*  and  others  believed  the 
rise  of  temperature  to  be  due  to  fibrin  ferments.  However,  it  would 
seem  to  be  caused  by  the  nucleins,  the  albumoses,  and,  to  some  extent, 
by  proteolytic  leukocytic  ferments. 

The  rise  of  temperature  in  brain  injury  is  probably  due  to  the 
irritation  or  destruction  of  certain  heat  centers  (corpus  striatum). 

Moderate  pyrexia,  without  the  systemic  disturbances  of  fever,  fre- 


190  INFECTIONS  OF  WOUNDS 

quently  follows  open  accidental  and  surgical  wounds.  This  also  has 
been  attributed  to  the  absorption  of  certain  decomposed  organic  ele- 
ments; however,  the  fact  that  bacteria  are  always  present  to  some 
extent,  under  these  conditions,  yet  not  giving  rise  to  sufficient  disturb- 
ance to  become  menacingly  manifest,  suggests  that  bacterial  poisoning 
may,  even  here,  be  the  causative  factor.  With  this  reservation,  the 
term  "aseptic  fever"  may  be  regarded  as  not  objectionable. 

Certain  afflictions  of  the  nervous  system ;  lunacy,  paralysis,  hysteria, 
etc.,  are  attended  with  fever,  no  doubt  due  to  irritation  of  the  heat 
centers. 

BIBLIOGRAPHY 

1.  Traube.     Miineli.  med.  Woch.,  1912. 

2.  Krehl,     Path.  Pliys.,  Leipzig,  1912. 

3.  ScHNiTZLER  and  Ewald.     Arch.  f.  klin.  Chir.  Bd.  53,  1896. 

4.  v.  Bergmann,     Festschr.  d.  Wiirzburger  Univ.,  1882. 


CHAPTER  VI 

PYOGENIC   MICROORGANISMS 

Bacteria  that  give  rise  to  purulent  inflammation  are  called 
'pyogenic  microorga^iisms ;  however  they  frequently  invade  the 
tissues  in  consort  with  putrefactive  bacteria. 

Pyogenic  organisms  may  be  subdivided  into  those  that  frequently 
cause  purulent  infection  (pus  cocci),  and  those  which  give  rise  to 
inflammatory  processes  in  which  the  formation  of  pus  is  compara- 
tively rare  (pneumococci,  gonococci,  bacillus  coli  communis,  bacillus 
pyocyaneus,  bacillus  typhosus,  etc.)-  None  of  the  so-called  pyogenic 
bacteria  are  purely  pus  producers;  they  are,  however,  all  phlogogen- 
ous,  giving  rise  to  inflammation  that  may,  or  may  not  (most  com- 
monly the  former),  result  in  the  formation  of  pus. 

The  discovery  of  living  organisms  in  pus  is  credited  to  v.  Wever, 
1863,  and  Rindfleisch,  1866.  In  1871  and  1872  v.  Recklinghausen, 
"Walddeyer,  Klebs,  Orth,  and  in  1873  Birch-Hirschfeld,  recognized 
micrococci  in  connection  with  pyemia,  puerperal  fever,  and  purulent 
inflammations.  In  1874  Billroth  furnished  valuable  evidence  in  this 
field. 

Accurate  observation  found  its  birth  in  the  basic  work  of  Rudolph 
Koch  regarding  the  etiology  of  wound  infection  (1878)  and  the  intro- 
duction of  transparent  culture  media  (1881).  In  1880-1882  Osgood 
diif erentiated  strepto-  from  staphylococci,  and  in  1883  Becker,  follow- 
ing the  methods  of  Koch,  cultured  staphj^lococci  from  osteomylitis, 
and  Fehleisen  did  the  same  with  the  streptococci  of  erysipelas. 
Rosenbach  (1884)  and  Passet  (1885)  succeeded  in  eulturing  various 
pyogenic  organisms. 

STAPHYLOCOCCI 

Staphylococci  are  spherical  fission  fungi,  usually  grouped  in  grape 
cluster  like  colonies. 

Classification. —  Staphj^lococcus  pyogenes  aureus,  pyogenes  albus, 
pyogenes  citreus,  cereus  albus,  and  cercus  flavus. 

191 


192 


INFECTIONS  OF  WOUNDS 


Morphology  and  Staining. —  The  staphylococcus  pyogenes  aureus, 
first  obtained  in  pure  culture  by  Becker,  later  by  Rosenbach,^  is 
usually  found  arranged  in  groups,  at  times  singly,  or  in  pairs 
(Fig.  107).  The  staphylococci  stain  with  all  the  usual  basic  aqueous, 
with  some  of  the  acid  dyes,  and  are  not  decolorized  b}'  the  Gram 
method.  Although  exhibiting  Brownian  movements,  staphylococci 
are  non-motile,  possess  no  flagella,  are  non-sporogenous,  and  form 
no  capsules. 

Cidtural  Characteristics. —  Staphylococci  grow  rapidly  upon  media 
commonly  used  in  the  laboratory.  The  optimum  temperature  for 
staphylococci   cultivation    is    about    30°C.    (86°F.),    though    growth 

occurs  at  15  °C. 
(59°F.),  and  as 
high  as  40  °C. 
(101°F.).  A  very 
slow  growth  has 
been  obtained  at 
10°C.  (50^F.). 

Most  luxuriant 

growth  takes  place 
under  aerobic  con- 
ditions, though 
staphylococci  are 
faculatively  anaero- 
bic on  certain  media. 
They  grow  readily 
in  an  atmosphere  of 


Fig.  107. 


STAPHYLororrus  Pyogenes  Aureus 
(Hiss  and  Zinsser). 


hj'drogen. 

On  gelatin  plates, 

growth  develops  at 
room  temperature  in  from  thirty-six  to  fortj'-eight  hours,  forming 
small,  shining,  pin-point  shaped  colonies,  appearing  at  first  grayish 
white,  and  later  assuming  a  yellowish  hue  which  intensifies  into  a  light 
brown,  and  often  a  bronze  color.  Liquefaction  of  the  gelatin  occurs, 
and,  after  forty-eight  hours,  saucer  shaped  excavations  are  formed 
ab6ut  the  colonies.  As  time  goes  on  the  areas  of  liquefaction  increase, 
and  ultimately  coalesce.  In  gelatin  slant  cultures  in  tuhes,  liquefac- 
tion causes  the  formation  of  a  slender,  funnel  shaped  depression,  with 
final  complete  liquefaction  of  the  medium,  and  sedimentation  of  the 
bacteria.    Liquefaction  of  gelatin  by  the  staphylococci  is  due  to  the 


PYOGENIC  MICROORGANISMS  193 

action  of  a  ferment  like  body  elaborated  by  it,  called  gelatinase 
(Loeb-).  Gelatinase,  an  extremely  thermolabile  body,  may  be  separ- 
ated from  the  cocci  by  filtration. 

On  agar  plates,  the  growth,  barring  liquefaction,  is  much  like  that 
on  gelatin  plates.  Colonies  do  not  coalesce,  but  remain  discrete  and 
show  marked  difference  in  size.  On  slanted  agar  in  tubes,  rapid 
growth  occurs,  at  first  grayish  white,  but  soon  covering  the  surface 
of  the  slant  with  a  golden  brown  layer. 

In  hroth,  growth  is  rapid,  leading  in  a  short  time  to  clouding  of  the 
medium,  and  after  forty-eight  hours  to  the  formation  of  a  surface 
pellicle.  Ultimately,  the  bacteria  gravitate  to  the  bottom,  forming 
a  heavy  pellucid  sediment.  Stale  cultures  emit  an  offensive  acrid 
odor. 

On  potato  and  hlood  serum,  growth  is  similar  to  that  on  agar. 

Eesistance. —  Staphylococci,  though  not  spore  formers,  are  very 
resistant  to  heat,  their  thermal  death  point  being  56°C.  (132.8°F.) 
to  58°C.  (136.4°F.).  Time  of  exposure  ten  minutes.  When  dry,  the 
coccus  resists  a  temperature  of  from  90 °C.  (194T.)  to  100  ^C. 
(212°F.)  (Sternberg^).  Staphylococci  are  also  very  resistant  to  low- 
temperature,  repeated  freezing  often  failing  to  sterilize  cultures. 

Desiccation  is  well  borne,  staphylococci  remaining  alive  for  from 
six  to  fourteen  weeks  when  dried  on  paper  or  cloth  (Deslongchamps*). 
On  slant  agar  the  cocci  may  be  left  for  three  or  four  months,  without 
transplantation,  and  remain  alive  (Passet^). 

Pathogenicity. —  Yellow  staphylococci  are  found  in  large  numbers 
under  a  great  variety  of  conditions,  and  vary  widely  in  virulence. 
The  most  highly  virulent  staphylococci  are  those  from  human  sup- 
purative lesions.  The  virulence  of  a  given  strain  may  be,  at  times, 
enhanced  by  repeated  passages  through  susceptible  animals.  Many 
staphylococci  are  constantly  present  in  the  air,  dust  and  water,  though 
these  are  probablj"  harmless  saprophj^tes. 

The  susceptibility  of  animals  to  staphylococcus  infection  is  ex- 
tremely variable,  depending  upon  differences  in  species  and  in  sus- 
ceptibility in  animals  of  the  same  species.  The  human  is  probably 
Ihe  most  susceptible  of  the  animals.  Mice  show  considerable  suscep- 
tibility; guinea  pigs  a  relatively  higher  resistance  (Terin*').  Inocu- 
lation beneath  the  skin,  or  intramuscularly,  usually  gives  rise  to 
abscess.  Intraperitoneal  or  intrapleural  inoculation  is  often  fatal. 
Intravenous  infusion  of  0.5  c.  cm.  of  fresh  culture  of  virulent  staphy- 
lococci leads  to  bacteremia  with  secondary  abscesses  in  kidney,  heart, 


194  INFECTIONS  OF  WOUNDS 

aud  Other  organs.  Staphylococcus  lesions  form,  histologically,  the 
typical  acute  abscess.  Tissues  subjected  to  trauma  preliminary  to  the 
introduction  of  staphylococcus  into  the  blood  are  frequently  the  site 
of  purulent  inflammation  (lowered  local  resistance).  The  bacteremia 
and  metastatic  abscess  formation  following  staphylococcus  invasion 
results  in  fatality,  early  or  late,  in  accord  wuth  the  virulence  of  the 
aggi-essor,  the  dosage,  and  the  resistance  of  the  host ;  large  doses  of 
virulent  cocci  cause  death  in  twenty-four  hours  or  less. 

Staphylococcus  infection  in  man  most  frequently  takes  on  the  form 
of  local  abscess  (furuncle,  etc.).  Garre,'^  Biidinger,^  Schimmelbusch,** 
and  others  have  demonstrated  by  experiments  upon  their  own  bodies 
that  energetic  rubbing  of  the  skin  with  virulent  staphylococcus  cul- 
tures is  often  followed  by  the  development  of  a  furuncle.  The  patho- 
logical lesions  consequent  to  infection  with  these  cocci  are  of  great 
variety.  They  are  the  incitants  of  surgical  suppurations  and  wound 
infection.  Most  acute  suppurative  inflammations  of  bone  (osteo- 
myeletis)  are  caused  by  them.  Abscesses  of  the  brain,  of  the  liver 
and  of  the  lungs  jnay  be  due  to  this  organism.  It  may  give  rise  to 
infections  of  the  genito-urinary  tract,  including  pyelonephritis  and 
empyema ;  or  suppurative  peritonitis  may  be  caused  by  invasion  of 
the  serous  surfaces  of  the  pleural  and  abdominal  cavities.  In  bac- 
teremia it  is  frequently  isolated  from  the  blood.  Puerperal  infection 
is  not  uncommonly  due  to  staphylococcus  invasion.  Massive  infec- 
tions with  staphylococci  give  rise  to  severe  manifestations,  i.  e.,  irregu- 
lar fever  and  its  sj'stemic  expressions.  Prolonged  infection  ultimately 
causes  amyloid  (so-called)  changes  in  the  liver,  spleen,  and  kidney's. 

A  means  of  determining  the  pathogenesis  of  the  various  strains  of 
staphylococci  has  been  difficult  to  obtain ;  however,  the  serodiagnostic 
method  of  Kolle  and  Otto^''  (see  below)  would  seem  worthy  of  consid- 
eration in  this  connection. 

Toxic  Products. — Endotoxins. —  Dead  staphj-lococci  injected  into 
animals  occasionally  cause  abscess  formation,  and,  if  in  sufficient 
quantity,  may  cause  death.  The  fact  that  large  dosage  is  necessary  to 
produce  a  fatal  result  suggests  that  the  endotoxic  substances  3'ielded 
by  the  dead  microorganisms  are  neither  very  poisonous  nor  abundant 
(v.  Lingelsheim^^).  Dead  cultures  of  staphylococcus  aureus  exert  a 
strong  positive  chemotaxis  for  leukocj'tes  (Borissow^^). 

Hemolysms. —  The  hemolytic  action  of  staphylococci  was  noticed  by 
Kraus^^  in  1900,  and  their  hemolysins  were  later  demonstrated  by 
Neisser    and    "Wechsberg.^*     The    hemolysins    are   produced    by    the 


PYOGENIC  MICROORGANISMS  195 

aureus,  and,  to  a  lesser  degree,  by  the  albus  organisms.  The  quantity- 
produced  varies  widely  with  different  strains.  Absolutely  avirulent 
strains  do  not,  so  far  as  is  known,  produce  hemolysins.  The  staphylo- 
hemolysin  is  comparatively  thermolabile ;  according  to  Neisser  and 
Wechsberg,  a  temperature  of  56 °C.  ( 132.8 °F.)  destroys  it,  though 
other  observers  consider  a  temperature  of  60°C.  (140°F.)  to  SCC. 
(176°F.)  necessary  for  the  purpose.  Reactivation  of  destroyed 
staphylo-hemolysins  has  not  succeeded.  Antistaphylob'sin  is  occa- 
sionally present  in  normal  sera ;  it  is  most  abundant  in  the  blood  of 
horses  and  of  man.  Artificially,  antistaphylolysin  formation  is  easily 
induced  by  subcutaneous  inoculation  of  staphylolysin  into  rabbits. 

Leukocidin. —  In  1894  Van  de  Yelde^-^  discovered  that  the  pleural 
exudate  of  rabbits,  following  the  injection  of  virulent  staphylococci, 
showed  marked  evidence  of  leukocyte  destruction.  The  substance 
causing  the  death  and  partial  solution  of  the  leukocytes  is  a  soluble 
toxin  formed  by  the  cocci,  not  only  in  vivo  but  also  in  vitro.  BaiP*^ 
obtained  leukocidin  by  growing  virulent  staphj'lococci  in  mixtures  of 
1  per  cent  glycerin  and  rabbit's  serum.  Leukocidin  is  obtained  pure 
by  passing  the  cultures  through  Chamberland  or  Berkefeld  filters, 
after  eight  to  eleven  days'  growth  at  37°C.  (98.6°F.),  at  which  time 
the  leukocidin  content  is  at  its  maximum. 

Not  all  staphylococcus  strains  produce  leukocidin  to  the  same 
degree.  Almost  all  true  staphylococcus  pyogenes  aureus  cultures  pro- 
duce the  toxin,  but  in  widely  varying  quantities.  Staphylococcus 
pyogenes  albus  rareh'  gives  rise  to  this  substance,  and  then  only  in 
small  quantities. 

Leukocidin  is  quickly  destroyed  by  heat  (58°C.-136°F.),  and 
deteriorates  rapidly  in  culture  fluids  at  incubator  temperature.  Its 
distinction  from  staphylohemolysin  is  shown  by  differences  in 
thermostability. 

By  treating  rabbits  with  pleural  exudate  containing  leukocidin, 
Denj's  and  van  de  Yelde^^  produced  an  antileukocidin.  Neisser  and 
Wechsberg  showed  that,  among  staphylococci,  leukocidin  is  not  spe- 
cific, the  toxins  of  all  strains  being  neutralized  by  the  same  antileuko- 
cidin, Antileukocidin  is  often  found  in  the  normal  sera  of  horses  and 
man  (van  de  Yelde'^). 

Staphylococci  also  give  rise  to  gelatinase,  and  to  a  proteolytic  fer- 
ment capable  of  slightly  digesting  albuminous  media  (Loffler's 
serum). 

Immunization. —  Efforts  at  immunization  have  not  given  practical 


196  INFECTIONS  OF  WOUNDS 

results  of  value.  Animals  have  been  rendered  actively  immune  by 
repeated  inoculations  with  carefully  graded  doses  of  living  or  dead 
staphylococcus  cultures  (Kichet  and  Hericourt^^).  The  blood  serum 
of  immunized  animals  has  been  found  effective  in  the  immunization 
of  other  animals  (v.  Lingelsheim^"). 

Kolle  and  Otto^°  used  the  blood  serum  of  rabbits  immunized  with 
large  quantities  of  staphylococcus  cultures  to  differentiate  pathogenic 
grape  cluster  cocci  from  the  saprophytes.  This  serum  has  the  quality 
(even  in  dilutions  of  1:100)  of  causing  the  agglutination  of  specific 
pathogenic  staphylococci.  Non-pathogenic  strains  of  cocci  are  not 
affected  in  this  way.  However,  the  question  of  the  agglutination 
capacity  of  human  serum,  as  applied  to  staphylococci,  may  not  be 
decided  in  this  manner,  as  agglutination  also  occurs  when  staphylo- 
cocci are  present  together  with  other  pathogenic  organisms,  and  the 
latter  only  are  responsible  for  the  infectious  process  (Beitzky-^). 

Antihemolysin  formation  has  been  used  for  diagnostic  purposes. 
Staphylolysins  cause  the  development  of  an  antitoxin  called  anti- 
hemolysin or  antilysin  which  neutralizes  the  action  of  lysins  (Neisser 
and  Wechsberg^*).  Bruck,  Michaelis,  and  E.  Sehultze-^  found  that 
the  formation  of  antilysin  in  cases  of  staphylococcus  infection  occurred 
frequently  but  not  constantly,  though,  when  it  occurred,  the  antilysin 
content  of  the  blood  exceeded  that  of  blood  of  the  healthy  human. 
Host  and  Saito^^  consider  this  reaction  as  important  in  differentiating 
chronic  purulent  osteomyelitis  from  bone  tuberculosis. 

Staphylococcus  Pyogenes  Albus,  first  cultured  by  Rosenbach,^  differs 
from  the  aureus  simply  in  the  absence  of  the  golden  yellow  coloration 
of  its  cultures.  Morphologically,  culturally,  and  pathogenically,  it  is 
in  every  way  identical  with  the  aureus.  Of  itself,  it  produces  milder 
forms  of  infection  than  the  aureus,  though  it  is  frequently  present 
Avhen  the  aureus  is  active.  As  it  lives  in  the  skin  it  is  frequently 
responsible  for  post  operative  wound  infection.  It  is,  however,  proper 
to  state  that  it  may  be  responsible  for  severe  and  even  fatal  general 
infections. 

The  Staphylococcus  Pyogenes  Citreus  and  the  cereus  alba  and  flavus 
(Passet^^)  are  of  minor  importance.  The  cultures  of  the  latter  two 
resemble  wax  drops  and  are  white  or  yellow  in  color;  they  are 
rarely  found  in  human  pus.  HentscheP*  found  the  staphylococ- 
cus citreus  in  the  pus,  in  the  blood,  and  in  the  spleen  of  a  fatal  case 
of  furuncle  of  the  lip. 


PYOGENIC  MICROORGANISMS 


197 


Anaerobic  Staphylococcus  (staphylococcus  aerogenes),  regarded  in 
some  instances  as  responsible  for  puerperal  fever,  has  been  described 
by  Schottmiiller.^^ 


STREPTOCOCCI 

Streptococci  multiply  by  division  in  one  plane  of  space  only,  an 
arrangement  which  gives  them  their  name.  The  term  "streptococ- 
cus" or  "chain  coc- 
cus" is  purely  mor- 
phological, and  in- 
cludes microorgan- 
isms which  may  dif- 
fer widely  as  to 
cultural  and  patho- 
genic properties. 
Many  strains  of 
cocci  may  have  little 
but  their  conforma- 
tion in  common  with 
the  pyogenic  strep- 
tococci so  imjDortant 
as  the  incitants  to 
disease. 

Streptococcus  Pyo- 
genes.—  Pure  cul- 
tures of  streptococci 
were  first  obtained 
by  Fehleisen-®  in 
1883  in  connection 
with  erysipelas,  and 
in  1884  Rosenbach^ 
cultured  pus  excit- 
ing streptococci. 
The  streptococcus 
pyogenes  is  not,  however,  to  be  regarded  as  specific  in  its  action 
as  applied  to  certain  infectious  diseases.  Its  classification  on  patho- 
logical and  clinical  bases  is  unsatisfactory,  as  all  streptococci,  irrespec- 
tive of  origin,  are  capable  of  provoking  infections  varj^ing  in  character 
of  expression.     Chain  cocci  transferred  from  a  mild  erysipelas  are 


'  /     -' 

-,./'. 

^         f^ 

\      f 

/    -'     / 

l» 

•    ^  / 

"***"    ( 

•'• 

/' 

V'^v.   - 

/'          "V 

>         ■"■--     ■  ■ 

t^_. 

Fig.  108.— Streptococcus  Pyogenes  (Hiss  and  Zinsser). 


198  INFECTIONS  OF  WOUNDS 

capable  of  provoking  severe  general  infection,  while  others,  originating 
in  severe  general  infection,  may  provoke  only  mild  erysipelas 
(Petruschky-').  The  clinical  picture  of  streptococcus  infection, 
therefore,  is  not  a  constant  one  and  is  not  dependent  upon  the  strain 
of  cocci  present,  but  upon  its  virulence  and  the  susceptibility  of  the 
host. 

Schottmiiller-^  has  attempted  a  classification  of  streptococci  patho- 
genic to  the  human,  based  upon  their  cultural  characteristics,  as 
follows :  Streptococcus  vulgaris,  erysipelatos,  viridans,  mucosus,  and 
putridus.  This  conception  would  not  seem  to  be  supported  by 
immunization  tests;  however,  most  observers  agree  that  a  distinct 
class  of  these  aggressors  exists  in  the  streptococcus  capsulatus  (Thal- 
mann,^^  et  al.). 

Morphology  and  Staining. —  The  individual  streptococcus  is  a  sphe- 
roid microorganism  measuring  from  0.5  micron  to  1  micron  in  diam- 
eter, at  times  showing  a  slight  flattening  of  its  surface.  As  fission 
takes  place  the  cocci  have  a  tendency  to  arrange  themselves  in  long, 
slender,  slightly  serpentine,  chains  (18  to  12  cocci  in  sequence) 
(Fig.  108),  though,  in  the  blood  and  in  exudates  of  virulent  infec- 
tions, they  frequently  take  on  the  form  of  diplococci.  Streptococci  do 
not  form  spores,  are  non-motile,  and  do  not  possess  fiagella. 

Pyogenic  streptococci  readily  stain  with  aniline  dyes,  and  are  not 
decolorized  by  the  method  of  Gram.  Certain  non-pathogenic  species 
are  Gram-negative  but  these  are  purely  saprophytic. 

Cultivation. —  The  pj^ogenic  streptococci  may  be  cultivated  upon  all 
richer  artificial  media.  Growth  on  meat  extract  peptone  media  is  not 
as  fertile  as  upon  media  which  have  beef  or  veal  for  a  basis.  Colonial 
flora  is  enhanced  by  adding  to  the  media,  animal  albumin  in  the  form 
of  blood,  blood  serum,  or  ascitic  transudate.  The  addition  of  glucose 
in  proportion  of  1  to  2  per  cent  stimulates  bacterial  growth.  Alka- 
linity of  the  media  is  desirable,  though  the  cocci  procreate  upon  neu- 
tral or  slightly  acid  media.  The  optimum  temperature  for  growth  is 
at  or  about  37.5°C.  (99.5°F.).  Above  43°C.  (109°F.)  to  45°C. 
(113°F.)  development  is  arrested.  At  from  15°C.  (59°F.)  to  20°C. 
(68°F.)  growth  is  faintly  maintained.  The  presence  of  oxygen  is 
important  to  the  growth  of  streptococci,  but  complete  anaerobiosis 
does  not  prevent  moderate  development.  Strictly  anaerobic  strepto- 
cocci have  been  cultivated  from  the  contents  of  the  human  gut 
(Perrone). 

In  broth  (alkalin),  at  37.5°C.  (99.5°F.),  pj^ogenic  streptococci  grow 


PYOGENIC  MICROORGANISMS  199 

rapidly,  and  form  long  tortuous  chains.  Clouding  rarely  occurs. 
When  sugar  has  been  added  to  the  broth,  the  formation  of  lactic  acid 
interferes  with  massive  development. 

In  milk,  at  37.5° C.  (99.5°F.),  the  streptococcus  pyogenes  grows 
readily,  and  soon  forms  acid  which  is  followed  by  coagulation  of  the 
medium. 

On  agar  plates  at  37.5°C.  (99.5°F.)  growth  is  manifest  within  from 
eighteen  to  twenty-four  hours,  in  the  form  of  small,  round,  trans- 
parent, closely  apposed  colonies.  Microscopicalh',  the  colonies  appear 
finely  granular,  and  seem  to  be  composed  of  long  intertwined  loops  of 
cocci  chains  which  form  fleecy  edges.  The  addition  of  ascitic  fluid  or 
blood  serum  is  followed  b}'  a  more  luxuriant  development  of  colonies. 

In  gelatin  stab  cultures,  growth  takes  place  slowly,  appearing  after 
twenty-four  to  thirty-six  hours  as  a  ver}^  thin  line,  or  as  disconnected 
minute  spheres  along  the  line  of  the  stab. 

On  gelatin  plates,  the  colonies  are  similar  in  form  to  those  on  agar, 
but  are  translucent  rather  than  transparent.  The  gelatin  does  not 
undergo  liquefaction. 

On  Loffler's  coagulatcel  hlood  serum,  growth  is  rapid  and  luxuriant, 
the  colonies  showing  a  tendency  to  confluence. 

On  potato,  growth  does  not  take  place  (Libman-*^). 

On  ■media  containing  red  Mood  cells,  most  streptococci  cause  hemo- 
lysis and  decolorization.  This  characteristic  is  valuable  in  connection 
with  bacterial  differential  diagnosis. 

In  the  inulin  serum  of  Hiss,^^  streptococci  do  not  produce  acid  and 
coagulation. 

Ordinarily  the  cultures  of  streptococci  rapidly  lose  virulence,  a  char- 
acteristic obviated  by  employing  the  method  of  Petruschky,  who  places 
gelatin  stab  cultures  in  the  refrigerator  for  two  days,  after  which 
virulence  is  maintained  for  several  montlis.  The  addition  of  a  small 
quantity  of  sterile  marble  dust  to  broth  cultures  achieves  the  same 
result. 

Resistance. —  Streptococci  on  the  ordinary  culture  media  M'ithout 
transplantation,  kept  at  room  temperature,  usually  die  within  ten  days 
to  two  weeks.  The  virulence  of  streptococci  is  not  readilj'  impaired 
by  drying;  indeed,  cocci  dried  on  blotting  paper  retain  pathogenesis 
for  a  long  period  of  time  (Petruschky^^).  Viability  is  prolonged  by 
the  use  of  calcium  carbonate  glucose  bouillon,  if  the  culture  and  the 
powdered  marble  are  thoroughly  shaken  from  time  to  time  (Hiss^°). 


200  INFECTIONS  OF  WOUNDS 

In  sputum  or  animal  excreta,  streptococci  may  remain  alive  for  several 
weeks. 

Streptococci  are  killed  by  exposure  to  a  temperature  of  54° C. 
(129.2°F.)  for  ten  minutes  (Sternberg^).  Low  temperature  and  even 
freezing  do  not  destroy  some  races. 

Chemical  destruction  of  streptococci  is  reported  by  v.  Lingelsheira 
as  follow" :  Carbolic  acid  1 :200  kills  the  cocci  in  about  fifteen  minutes. 
In  the  same  period  of  time  bichlorid  of  mercury  is  efficient  in  dilutions 
of  1 :1500,  lysol  in  a  dilution  of  1 :200,  hydrogen  peroxid  1 :35,  sulphuric 
acid  1 :150,  and  hydrochloric  acid  1 :1150.  Inhibition  is  exerted  by 
carbolic  acid  1 :550,  and  by  bichlorid  of  mercury  1 :65000.  Exposure 
to  direct  sunlight  kills  streptococci  in  a  few  hours. 

Virulence  and  Pathogenicity. —  Different  races  of  pathogenic  strepto- 
cocci show  wider  variation  in  virulence  than  obtains  in  most  patho- 
genic organisms.  The  degree  of  severity  of  the  lesion  in  man  is  not 
indicative  of  the  virulence  of  the  organism  in  animals.  These  differ- 
ences are,  to  a  certain  extent,  dependent  upon  inherent  individual 
characteristics,  but  are  most  likely  the  consequences  of  previous  envir- 
onment or  habitat.  Prolonged  cultivation  upon  artificial  media 
usually  results  in  a  lessening  of  virulence  of  the  coccus,  while  an 
originally  low  virulence  may  be  enhanced  by  repeated  passage  of 
streptococci  through  animals  generally,  and  repeated  passages  through 
mice  may  increase  the  virulence  for  these  animals  only,  even,  at  times, 
lessening  pathogenesis  for  rabbits  (Knorr^-). 

White  mice  and  rabbits  are  exceedingly  susceptible  to  streptococcus 
infection;  guinea  pigs  and  rats  less  so,  while  the  larger  domestic 
animals,  cattle,  horses,  goats,  cats,  dogs,  etc.,  are  extremely  resistant. 
Birds  are  almost  completely  immune  (Hiss^^). 

The  character  of  lesions  following  animal  inoculation  depends  upon 
the  dosage,  and  upon  the  degree  of  virulence  of  the  cocci  used.  Sub- 
cutaneous injection,  according  to  the  virulence  of  the  inoculated  mate- 
rial, may  result  in  the  formation  of  abscess,  differing  from  staphylo- 
coccus abscess  in  the  severity  of  the  local  process,  or  with  only  slight 
local  disturbance,  a  severe  general  bacteremia  may  develop.  Intra- 
pleural or  intraperitoneal  inoculation  of  susceptible  animals  with  viru- 
lent streptococci  usually  provokes  a  hemorrhagic  form  of  exudate,  due 
to  the  diapedesis  caused  by  the  violence  of  the  inflammatory  process, 
and  to  the  hemolysis  of  the  red  cells  by  the  streptococcic  hemolysins. 
Inoculation  of  rabbits,  at  the  base  of  the  ear,  with  virulent  streptococci 
not  infrequently  provokes  the  development  of  a  lesion,  histologically 


PYOGENIC  MICROORGANISMS  201 

closely  allied  to  erysipelas  in  man  (FehJeisen^*).  Marbaix^^  has 
shown  that  these  erysipeloid  lesions  could  be  produced  in  rabbits  by 
streptococci  from  various  sources,  provided  the  virulence  of  the 
special  strain  was  sufficiently  enhanced.  This  variability  of  lesion,  as 
determined  by  the  degree  of  virulence  of  the  incitant,  irrespective  of 
its  source,  forms  a  strong  argument  in  favor  of  the  opinion  that  all 
pyogenic  streptococci  are  members  of  a  single  species  (Hiss^^). 

The  introduction  of  virulent  cultures  into  the  circulation  (vein)  of 
the  rabbit  is  followed  by  a  rapid  fatal  outcome.  Autopsy  shows  sero- 
sanguineous  edema  at  the  point  of  moculation,  multiple  hemorrhagic 
spots  on  serous  membranes,  and  congestion  of  viscera.  The  cocci  are 
almost  invariably  to  be  found  in  the  blood,  in  the  heart,  in  the  spleen, 
and  in  the  exudate  about  the  port  of  entrance.  When  the  process  is 
prolonged  parenchymatous  degeneration  of  all  the  organs  occurs.  In 
the  chronic  forms  of  infection,  articular  and  periarticular  lesions 
develop.  As  a  rule,  spontaneous  streptococcus  infection  is  rare  among 
animals.  However,  a  contagious  form  of  inflammation  of  the  respira- 
tory passages  of  horses  has  been  attributed  to  streptococcus  infection 
(van  de  Velde^^).  Among  cattle,  the  organism  has  produced  inflam- 
mation of  the  udder  and  also  uterine  inflammation.  An  epidemic 
disease  among  white  mice  due  to  streptococcus  is  reported  by  Kuts- 
cher.^'^ 

In  man,  streptococci  stand  in  a  caustive  relation  to  a  large  variety 
of  pathological  processes,  the  nature  of  which  depends  upon  the  viru- 
lence of  the  invading  cocci  and  the  resistance  of  the  host.  The  so-called 
streptococcus  erysipelatos  (Fehleisen)  is  no  longer  regarded  as  essen- 
tially diifereut  from  other  streptococcus  pj^ogenes.  Superficial,  local- 
ized infection  may  be  caused  by  streptococci  wdiich  differ  from  those 
provoked  by  staphylococci  only  with  respect  to  intensity  (greater  in 
the  former).  Severe  infection  is  attended  wdth  rapidly  spreading 
cellulitis,  lymphangitis,  phlebitis,  and  grave  constitutional  distur- 
bances often  threatening  life. 

The  fact  that  streptococci  are  frequently  found  upon  the  mucous 
membranes  of  the  normal,  or  diseased,  upper  air  passages,  argues  that 
they  find  there  conditions  favorable  to  their  existence.  However, 
their  simple  presence  is  not  sufficient  to  provoke  pathological  pro- 
cesses ;  pathogenesis  develops  when  there  is  a  sudden  increase  in  Vwvl- 
lence,  or  wdien  local  resistance  is  reduced  as  the  result  of  trauma, 
refrigeration,  etc. 


202  INFECTIONS  OF  WOUNDS 

Streptococci  located  in  the  nose  and  mouth  may  be  expelled  by  the 
act  of  sneezing  and  coughing,  and  find  residence  in  environment  where 
pathogenesis  is  developed;  they  may  be  swallowed  with  the  saliva 
and  gain  access  to  the  gastro-intestinal  canal.  That  they  are  not 
destroyed  by  the  gastric  or  intestinal  juices  is  shown  by  the  occurrence 
of  virulent  streptococcus  peritonitis  following  perforating  gastric  or 
intestinal  ulcer,  perforating  appendicitis,  and  the  presence  of  strep- 
tococci in  the  fluid  transuded  from  strangulated  gut  (in  hernia). 
Streptococci  in  milk  have  given  rise  to  streptococcus  enteritis,  peri- 
tonitis, and  .streptococcemia  in  nursing  infants  (Jehle^*). 

Streptococcus  infection  occurs  in  all  the  parts,  organs,  and  tissues 
of  the  body  and  is  rarely  mild  in  character.  Streptococcemia  is  uni- 
formly fatal.  Metastases  do  occur ;  but  the  general  infection  is  usually 
so  severe  that  death  results  before  secondary  foci  develop. 

Standardization  of  the  A'irulence  of  a  given  strain  of  streptococci  is 
difficult,  because,  one  pathogenic  to  man  may  be  non-pathogenic  to 
(he  lower  animals.  Specific  virulence  (for  a  given  animal)  is  only 
attained  after  frequent  reinoculation  into  a  number  of  certain  kinds  of 
animals,  and  when  this  is  once  established  virulence  as  regards  the 
Imman  is  lost  (Petruschk}'^^).  Streptococci  virulent  for  guinea  pigs 
lose  their  virulence  as  regards  these  animals  after  passing  through 
mice;  consequently,  streptococci  of  human  origin  are  most  dangerous 
to  man,  a  fact  borne  out  by  clinical  observations. 

Toxic  Products. —  An  understanding  of  the  nature  of  the  poisons 
produced  by  streptococci  is  very  incomplete.  The  grave  systemic  dis- 
turbances accompanying  comparatively  moderate  streptococcus  lesions 
suggest  that  a  powerful  diffusible  poison  is  produced  by  these  or- 
ganisms. Poisons  have  been  obtained  by  filtration  (Marmorek,^** 
Baginsky,'*°  and  others)  ;  however,  these  have  not  shown  the  potency 
evinced  by  those  of  diphtheria  and  tetanus.  Large  doses  of  the  toxin 
injected  into  guinea  pigs  produce  collapse  and  death.  Failure  to 
obtain  potent  toxins  is  attributed  to  the  meagerness  of  the  cultural 
flora  of  the  coccus  in  fluid  media,  which  Marmorek  ascribes  to  the  self- 
limited  genesis  of  the  organism ;  this  is  also  explained  on  the  ground 
that  the  growth  of  the  bacterium  is  attended  by  the  formation  of  acid 
which  inhibits  its  development.  This  last  factor  can  be  partially  over- 
come by  the  use  of  glucose  calcium  carbonate  broth,  in  which  acid 
neutralization  constantly  takes  place  (Hiss  and  Zinsser^^).  Baginsky 
and  Sommerfield'*°  advise  a  strongly  alkaline  reaction  of  the  media. 


PYOGENIC  MICROORGANISMS  203 

The  toxins  produced  iii  the  manner  stated  are  relatively  thermostabile. 
Heating  to  60°C.  (140°F.)  destroys  them  in  part  only.  The  endo- 
toxins of  streptococcus  cell  bodies  possess  only  slight  toxicity.  It  is 
probable  that  streptococcus  toxins  are  only  produced  in  living  tissue 
under  circumstances  favorable  to  the  growth  of  the  bacteria  (v, 
Lingelsheim^^). 

Hemolysins  are  produced  by  streptococci  that  have  the  power  to 
destroy  red  blood  corpuscles  (Marmorek*-)  ;  hemolysis  is  proportionate 
to  the  virulence  of  the  infection.  Schottmiiller"  disputes  this,  be- 
lieving hemolysis  to  be  a  constant  in  certain  strains  unchangeable  by 
experimental  enhancement,  or  the  reduction  of  virulence.  Besredka** 
and  Schlesinger^^  believe  that  the  hemolytic  substances  are  closely 
attached  to  the  bacterial  bodies.  Sclilesinger*'"  regards  streptococcus 
hemolysins  as  extremely  labile,  as  they  disappear  from  culture  fluids 
after  standing  for  from  five  to  seven  days  at  room  temperature. 

Immunization. —  Recovery  from  streptococcus  invasion  does  not 
seem  to  produce  immunity  from  reinfection.  The  blood  serum  of 
immunized  animals  (rabbits,  mice,  ass,  horse,  etc.)  provides  pro- 
tection against  ordinarily  fatal  inoculation.  As  streptococci,  patho- 
genic to  animals  are  non-pathogenic  to  man,  it  is  questionable  if  the 
sera  of  animals  treated  with  the  human  streptococci  have  any  immu- 
nizing capacity  for  the  human.  Koch  and  Petruschky*"  attempted  to 
immunize  the  human  against  erysipelas  without  success.  Tavel's 
serum  and  the  commercial  sera  have  not  proven  of  great  value.  The 
conception  of  their  action  is  based  on  the  notion  that  they  stimulate 
phagocjiiosis  and  possibly  increase  the  opsonins.  A  serum,  to  be  effec- 
tive against  streptococci,  pathogenic  to  the  human,  would  have  to  be 
derived  from  animals  susceptible  to  the  same  race  of  cocci  as  is  man 
(Zangemeister^').  Looking  into  the  future,  the  most  productive  field 
in  this  connection  would  seem  to  lie  in  the  study  of  the  serum  of  the 
human  recovered  from  general  streptococcus  infection  (Zange- 
meister*'). 

Streptococcus  infection  is  so  destructive  to  life  and  function  that  no 
effort  at  lessening  its  ravages  should  be  minimized.  Van  de  Velde," 
Denys,*^  Aronson,^''  and  many  others  have  done  persistent  work  in 
this  connection.  The  sum  of  their  efforts  would  seem  to  justify  the 
emplojTnent  of  "  poh"V'alent  "  sera  (immunizing  animals  with  a  large 
variety  of  streptococcus  races,  derived  from  many  different  human 
sources) . 


204  INFECTIONS  OF  WOUNDS 

Leukocyte  extracts  have  produced  favorable  results  in  erysipelas 
(Hiss^^). 

The  agglutinins  found  in  streptococcus  immune  sera  are  most  active 
toward  the  strain  of  bacteria  used  in  the  immunization.  While  a 
specific  group  reaction  is  useful  in  differentiating  streptococcus  from 
other  species,  agglutination  cannot  be  relied  upon  to  differentiate 
individual  streptococci  from  one  another  (Hiss^^).  It  has  been  found 
that  a  serum  produced  from  a  streptococcus  from  one  source  contains 
a  higher  agglutinating  value  for  some  other  streptococcus  than  for 
the  one  employed  in  its  production.  Agglutinins  may  be  produced  by 
treating  animals  with  dead  as  well  as  living  streptococci. 

Precipitins  haA'e  been  found  in  streptococcus  immune  horse  serum. 
The  group  differentiation  of  streptococci  has  been  studied  by  Wins- 
low  and  Palmer^^  by  determining  the  amount  of  acid  formed  in 
various  sugars.  Hopkins  and  Lang  seem  to  show  that  the  streptococci 
found  in  most  human  infections  may  be  differentiated  from  the 
ordinary  saprophytic  types  by  the  fact  that  they  ferment  lactose  and 
salicin,  but  fail  to  ferment  raffinose,  inulin,  or  mannite. 

Aronson,^^  Marmorek,^^  and  others  have  shown  that  the  most 
reliable  method  of  determining  the  inter-relationship  existing  between 
bacteria,  is  that  of  depending  upon  their  reactions  to  immune  sera. 
Streptococcus  immune  sera,  produced  with  any  one  race  of  pyogenic 
streptococci,  exert  considerable,  though  variable,  protective  action 
against  many  other  strains  of  streptococci.  The  agglutinins  produced 
with  one  streptococcus  strain  are  active  against  many  other  strepto- 
cocci; again,  a  serum  produced  with  a  streptococcus  from  a  septic 
infection  may  agglutinate  a  streptococcus  from  a  scarlatina  infection ; 
as  with  other  ''gToup  agglutinations,"  the  more  highly  immune  the 
serum  is,  the  more  general  is  the  agglutinating  power  over  the  whole 
group.  Thus,  while  agglutination  is  practically  useless  in  separating 
streptococci  from  one  another,  it  is  highly  useful  in  differentiating 
these  organs  from  allied  groups,  such  as  pneumococci.  The  immune 
reactions,  therefore,  seem  to  indicate  a  very  close  relationship  between 
streptococci  as  a  class. 

DIPIOCOCCTJS  PNEUMONIAE 

The  diplococcus  or  streptococcus  lanceolatus  in  its  relationship  to 
fibrinous  pneumonitis  was  discovered  by  A.  FraenkeP*  (1886),  and 
verified  in  this  connection  by  Weichselbaum,^^  Pasteur^^    (1881)   in- 


PYOGENIC  MICROORGANISMS 


205 


oculated  the  organism  from  human  sputum  into  rabbits,  and  caused 
the  development  of  fatal  general  infection  (so-called  sputum  septi- 
cemia). Rosenbach/  who  found  the  coccus  in  pus  (1884),  gave  it  the 
name  of  micrococcus  pj'ogenes  tenius.  Gradually  the  organism  has 
been  recognized  as  standing  in  a  causative  relationship  to  a  number 
of  inflammatory  processes,  other  than  so-called  pneumonia. 

Morphology  and  Staining. —  The  morphology  of  the  pneumococcus  is 
the  most  distinctive  guide  to  its  identit}^  The  single  half  of  the 
diplococcus  is  lancet  shaped,  or  candle  flame  in  form.  The  cocci  are 
surrounded  in  pairs  by  a  definite  wide  capsule  (Fig.  109)  wdiich 
usually  symmetrically  encircles  two  approximated  cocci.    The  pneumo- 

cocci  may,  however,  occur  singiy  or 
in  short  chains.  This  may  be  due 
to  the  cultural  conditions,  or  may  be 
a  characteristic  of  certain  chains. 
The  pneumococcus  is. non-motile,  and 
possesses  no  flagella.  Spores  are  not 
formed. 

Staining  of  pneumococcus  is  read- 
ily accomplished  with  all  the  usual 
a({ueous  aniline  dyes.  It  is  not  de- 
colorized by  Gram.  The  capsule 
may  be  stained  by  the  glacial  acetic 
acid  method  (Welch-^')  and  the  cop- 
per sulphate  method  (Hiss'^'^). 

Cultivation. —  The    pneumococcus, 

because  of  its  parasitism,  is  difficult 

to  cultivate.     In  meat  extract  media, 

growth  does  not  take  place. 

Colonization  occurs  most  regularlj^  at  a  temperature  of   37.5° C. 

(99.5°F.).     Growth  ceases  below  25°C.    (77°F.),  and  above  41°C. 

(105. 8°F.).  At  room  temperature,  growth  is  slight. 

Pneumococci  grow  under  both  aerobic  and  anaerobic  conditions. 
There  is  little  difference  in  rapidity  or  degree  of  growth  in  stab 
cultures.  Alkalinity  of  media  favors  growth.  Growth  may  be  en- 
hanced by  the  addition  of  animal  or  human  serum,  or  whole  blood  to 
the  media ;  the  addition  of  acid  hastens  the  death  of  the  cocci. 

In  'broth,  pneumoccocus  growth  is  rapid,  leading  to  clouding  of  the 
fluid  in  twentj'-four  hours,  which  eventually  disappears.  When  glu- 
cose is  added,  growth  is  prolific,  but  acid  formation  causes  the  cultures 


w 

^j^    -^  1 

E 

*                                                         ! 
*• 

--^ 

Fig.  109. — ■  Pneumococci  Grown  on 
Loffler's  Serum  (Hiss  and  Zins- 
ser). 


206  INFECTIONS  OF  WOUNDS 

to  die.     Broth  cultivation  is  well  adapted  to  the  production  of  mass 
cultures  for  purposes  of  immunization  and  agglutination  (Hiss^®). 

Upan  agar  plates,  pneumococcus  growth  resembles  that  of  strepto- 
coccus. The  colonies  appear  more  moist  and  are  flatter  than  those  of 
the  streptococcus. 

In  gelatin  plate  and  stah  cultures,  at  22°C.  (71.6°F.)  growth,  as 
a  rule,  does  not  take  place.  This,  how^ever,  is  not  true  of  all  strains 
of  pneumococci,  some  of  which  will  grow  fairly  well  in  gelatin  at 
the  temperature  stated. 

Upon  mixtures  of  whole  rahhit's  Mood  and  agar,  the  pneumococcus 
forms,  after  four  or  five  days,  thick  black  surface  colonies,  easily  dis- 
tinguished from  those  of  streptococci,  which  are  of  considerable  dif- 
ferential value  (Hiss''^). 

Resistance. —  On  artificial  media,  the  viability  of  the  pneumococcus 
is  not  great,  transplantation  at  intervals  of  three  or  four  days  being 
necessary  to  maintain  the  flora.  In  media  containing  albumin,  and  of 
proper  reaction,  preservation  for  one  or  two  weeks  is  feasible.  The 
length  of  life  may  be  increased  by  preservation  at  a  low  temperature, 
in  the  dark,  and  by  the  exclusion  of  air. 

In  sputum,  the  viabilitj'  of  the  pneumococcus  seems  to  exceed  that 
observed  in  cultures.  Guarnieri,^'*'  Bordoni-Uffreduzzi,'^"  and  others 
have  shown  that  pneumococci  slowly  dried  in  sputum  may  remain 
alive  for  one  to  four  months  M'hen  protected  from  light  and  for  nine- 
teen days  when  exposed  to  diffused  light  at  room  temperature.  Ex- 
posed to  strong  sunlight,  pneumococci  die  within  a  few  hours. 

Low  temperature,  slightly  above  zero,  is  conducive  to  the  prolonga- 
tion of  life,  and  the  preservation  of  virulence. 

The  resistance  of  the  pneumococcus  is  low,  52°C.  (125. 6°F.)  destroy- 
ing it  in  ten  minutes  (Sternberg**^).  To  germicidal  agents,  carbolic 
acid,  bichlorid  of  mercury,  etc.,  the  pneumococcus  is  sensitive,  being 
destroyed  by  weak  solutions  after  short  exposures.  Pneumococcus 
exudates  are  most  rapidly  destroyed  by  20  per  cent  alcohol  (Wads- 
worth"-). 

Virulence  and  Pathogenicity. —  The  variable  virulence  of  the  pneu- 
mococcus has  alread}'  been  taken  up  in  connection  with  its  cultivation 
(see  above).  '  Attention  is  called  to  the  prolonged  virulence  of  the 
coccus  in  dried  sputum,  its  resistance  to  refrigeration,  and  its  menace 
in  connection  with  the  lowered  resistance  of  the  host. 

In  man  the  most  frequent  lesion  produced  by  the  pneumococcus  is 
ficute    (fibrinous)    pneumonia    (71   per   cent,   Weichselbaum-'^).      Its 


PYOGENIC  MICROOKGANISMS  207 

pathogenetic  relationship  to  pleuritis,  peritonitis,  endo-pericarditis, 
meningitis,  synovitis,  purulent  osteomyelitis,  etc.,  may  be  complications 
of  processes  in  the  lungs,  though  this  association  is  not  by  any  means 
constant.  Indeed,  each  of  the  inflammatory  processes  mentioned  may 
occur  entirely  independent  of  lung  infection.  In  this  lies  the  surgical 
import  of  the  pneumococcus.  The  coccus  is  not  infre(iuently  found  to 
be  the  cause  of  wound  infection  (Green*'^),  bacteremia,  and  the  forma- 
tion of  metastatic  foci.  The  pneumococcus  is  the  most  frequent  cause 
of  frontal  and  maxillary  sinusitis,  otitis  media,  and  parotitis.  The 
cocci  may  be  swallowed,  and  thus  gain  access  to  the  peritoneum,  either 
through  ulcers  or  directly  through  the  mucoi-a  of  the  gastro-intestinal 
canal,  and  give  rise  to  peritonitis  (Weichselbaum,-^''  de  Quervain^^). 
Hematogenous  pneumococcus  peritonitis  in  pneumonitis  is  rare 
(Jensen^^).  Pneumococcus  appendicitis,  either  alone  or  as  a  compli- 
cation of  pneumonitis,  has  not  infrequently  been  observed. 

Toxic  Products. —  Attempts  to  obtain  soluble  toxins  by  filtration  of 
pneumococcus  cultures  has  not  been  productive  of  success,  despite  the 
efforts  of  Klemperer,*^*'  Mennes,^^  Pane,''^  Foa  and  Carbone,*'^  and 
others.  This  failure  seems  to  show  the  potent  toxin  of  pneumococci  to 
be  an  endotoxin,  closely  associated  with  the 'cellular  elements  of  the 
cocci  themselves  (Macfayden^°).  Toxic  substances  have  been  obtained 
by  extracting  the  cocci  with  salt  solution  and  bile  (Cole^^). 

Immunization. —  Healed  pneumococcus  infection  is  not  followed  by 
durable  immunity'.  Active  immunity  may  be  established  in  animals 
by  the  exercise  of  great  care  in  the  dosage  of  dead  or  attenuated 
cocci. 

Agglutinins  studied  by  Neufeld,''^^  Hiss,^*  et  al.  may  be  obtained  by 
cultivating  the  pneumococcus  in  a  1  per  cent  glucose  broth  to  which 
is  added  small  quantities  of  sterile  calcium  carbonate  to  absorb  the 
acid  formed  by  the  glucose.  Agglutinations  are  best  studied  in  sus- 
pensions of  concentrated  immune  serum. 

The  reaction  of  the  pneumococcus  group  to  immune  serum  seems 
to  show  the  existence  of  several  varieties  of  the  organism  (Dochez  and 
Gillespie^^).  It  would  also  appear  that  the  organism  may  be  trans- 
mitted by  carriers   (Dochez  and  Avery'^*). 

Precipitins  have  been  demonstrated  in  pneumococcus  immune 
serum,  the  organism  for  the  test  being  brought  into  solution  with  bile 
or  with  concentrated  salt  solution  (Neufeld,'-  Hiss''^).  Such  sera  also 
contain  powerful  opsonic  substances,  the  "  bacteriotropins  "  of  Neu- 


208 


INFECTIONS  OF  WOUNDS 


feld  and  Rimpau/^  which  seem  actively  to  stimulate  phagocytosis,  and 
are  concerned  in  protection  and  recovery. 

Attempts  to  produce  passive  immunity  in  man,  though  not  yet 
crowned  with  definite  results,  would  seem  to  offer  hope  for  the 
future  in  connection  with  the  agglutination  of  the  various  strains  of 
pneumococci  in  homologous  sera  (Hiss  and  Zinsser^^). 


MICROCOCCUS  TETRAGENUS 

A  micrococcus  which  occurs  regularly  in  groups  of  four  or  tetrads, 
was  isolated  from  the  exudate  of  a  case  of  pulmonary  tuberculosis 
by  Gatfky"*'  (1881),  Observed  in  smear  preparations  from  pus,  the 
tetrads  are  slightly  larger  than  staphylococci,  are  flattened  along 


Fig.  110. —  Micrococcus  Tetragenus  (in  spleen  of  infected  mouse) 
(Hiss  and  Zinsser). 

their  adjacent  surfaces,  and  are  surrounded  by  a  thick  areolar  capsule 
(Fig.  110).  The  micrococcus  stahfs  readily  with  the  usual  basic 
aniline  dyes,  and  is  not  decolorized  by  Gram's  method. 

Cultivation. —  The  micrococcus  tetragenus  grows  on  the  media  ordi- 
narily used  in  the  laborator^^,  showing  a  less  fertile  colonization  than 
do  staphylococci. 

Oji  agar,  the  colonies  are  at  first  transparent,  later  gra^'ish  white  in 
appearance. 

On  gelatin,  growth  is  indolent  and  no  liquefaction  takes  place. 

Milk  is  coagulated  and  becomes  acid. 

Pathogenicity. —  Japanese  mice  succumb  in  three  or  four  days  after 
subcutaneous  inoculation  (Miiller'^'^).  Graj-  mice,  rabbits  and  guinea 
pi^  show  only  a  localized  reaction  at  the  point  of  inoculation. 


PYOGENIC  MICROORGANISMS 


209 


In  man,  the  micrococcus  is  found  in  non-pathogenic  sputum  and 
saliva.  It  has  been  found  as  the  sole  excitant  of  abscess.  Bezangon'^ 
has  isolated  it  from  a  case  of  meningitis,  and  Forneaca"  (1905)  re- 
ported a  case  of  tetragenus  bacteriemia. 


DIPLOCOCCUS  GONORRHEAE 

The  excitant  of  gonorrhea  was  discovered  by  Neisser^°   (1879)   in 
purulent  discharges  from  the  human  urethra  and  obtained  in  pure 
culture  (human  blood  serum)  by  Bumm^^  (1885), 
who    also    successfully    inoculated    the    healthy 
urethra  with  the  organism. 

Morphology  and  Staining. — The  gonococcus  usu- 
ally appears  in  the  form  of  a  diplococcus,  the 
pairs  being  flattened  along  their  opposed  surfaces, 
which  gives  them  a  peculiar  coffee  bean  or  biscuit 
shape.  The  size  of  the  diploforms  is  about  1.6 
microns  long  and  about  0.8  micron  in  diameter. 

In  acute  infections,  staining  shows  the  cocci  ar- 
ranged both  intra-  and  extra-cellularly,  a  num- 
^^1  ber  crowded  into  the  leukocyte  body,  though  they 

~"~  -i   do   not   invade   the   nuclear    areas    (Fig.    111). 

Scholtz*-  has  shown  that  the  cocci  are  located  in- 
tracellularly  only  in  free  exudates,  and  not  in  the 
Fig  111  —  GoxoR-  ^^Pt^is  of  the  tissues;  it  is  less  uniformly  so  in 
RHEAL  Pus  FROM  chrouic  dischargcs  of  exudate.  In  smears  from 
theTo^cc:^  wi™  P^^®  cultures  the  arrangement  in  groups  of  two 
A  Leukocyte  (Hiss  is  less  marked  than  in  pus,  clusters  of  eight  or 
and  Zinsser).  ^^^^^  ^^j^^^  common. 

The  gonococcus  is  non-motile  and  does  not  form  spores. 

Gram's  method  of  staining  is  the  only  one  of  differential  value,  the 
gonococcus  being  Gram  negative,  though  the  microorganism  stains 
readih'-  with  methylene  blue. 

Cultivation. —  The  gonococcus  will  not  grow  on  ordinary  culture 
media.  The  medium  most  effectually  used  is  three  parts  of  meat  in- 
fusion agar  with  one  pint  of  uncoagulated  human  ascitic  fluid,  hydro- 
cele fluid,  or  blood  serum  ("Wertheim-").  The  cultural  flora  of  the 
gonococcus  differs  with  various  strains.  After  several  generations  of 
growth  on  artificial  media,  the  organism  develops  with  increasing 
ease.    Recently  several  strains  of  gonococci  have  been  isolated  by  Hiss 


210  INFECTIONS  OF  "WOUNDS 

and  Zinsser^^  which  grew  rapidly  on  simple  media,  in  the  second 
culture  generation. 

The  gonococcus  will  develop  sparsely  only  under  anaerobic  condi- 
tions, but  grows  best  with  aerobiosis.  The  optimum  temperature  is 
37.5°C.  (99.5°F.).  Growth  ceases  above  38.5°C.  (101.3°F.),  and 
below  30°C.  (86°F). 

Tcague  and  Torrey^*  have  shown  that,  immunologically  gonococci 
can  be  divided  into  a  number  of  different  groups.  By  cross  agglutina- 
tions, and  by  agglutinin  absorption,  it  may  be  seen  that  gonococci  fall 
into  about  ten  groups,  which  are  serologically  separable  one  from  the 
other.  In  making  complement  fixative  tests,  it  is  necessary  to  make 
a  polyvalent  antigen  in  which  these  various  groups  are  represented. 

Resistance. —  The  cultural  flora  of  the  gonococcus,  if  not  trans- 
planted, dies  out  in  from  five  to  six  days  at  incubator  temperature. 
At  room  temperature  it  dies  more  rapidly. 

The  gonococcus  is  killed  by  a  temperature  of  41° C.  (105.8°F)  to 
42°C.  (107. 6°F.).  Drying  destroys  it  in  a  short  time;  incompletely 
dried  and  protected  from  light,  it  may  live  from  eighteen  to  twenty- 
four  hours  (Heiman^^).  It  is  destroyed  by  chemical  germicides  in 
weak  solution,  and  is  especially  vulnerable  to  silver  salts. 

Pathogenicity. —  Gonorrheal  infection  is  peculiar  to  man.  A  genu- 
ine gonorrheal  infection  has  never  been  engrafted  upon  the  lower 
animals;  however,  when  inoculated  into  the  peritoneum  of  mice  and 
guinea  pigs  circumscribed  purulent  peritonitis  occurs.  As  the  cocci 
soon  die  when  inoculated  into  animals,  the  consequent  disturbances 
must  be  ascribed  to  the  action  of  their  toxins.  This  would  seem  to  be 
substantiated  by  the  fact  that  purulent  infections  of  joints  may  be 
produced  by  dead  cultures  (Nicolaysen^°), 

Gonorrheal  infections  most  frequently  invade  the  genital  tract, 
causing  urethritis,  prostatitis,  cystitis,  epididjTnitis,  orchitis,  ureteritis, 
pyelitis  of  the  kidney,  and  corresponding  conditions  in  the  female.  In 
both  sexes  the  coccus  may  lie  dormant  for  years  and  be  stimulated  to 
exacerbation  of  growth  and  reinfection  develop. 

By  entrance  into  the  circulation,  the  gonococcus  is  not  infrequently 
responsible  for  general  infection,  endocarditis,  pleuritis,  meningitis, 
peritonitis,  synovitis,  perichondritis,  osteomyelitis  (Heyman,^^  Holm- 
berg,*^  Ullmann^"),  and  parotitis  (Colombilii^°).  Pure  gonococcus 
metastases  are  not  of  a  particularly  virulent  character,  and  spon- 
taneous restitution  to  the  normal  occurs  in  most  instances.     "When 


PYOGENIC  MICROORGANISMS  211 

more  stormy  and  persistent  symptoms  develop,  they  may  be  ascribed 
to  an  added  pyogenic  infection. 

Toxic  Products. —  Gonococcic  toxins  are  liberated  upon  the  death  of 
the  cocci  (Nicolaysen'*^).  De  Christmas'*-  claims  to  have  isolated  a 
toxin  from  culture  fluids.  On  the  other  hand,  the  emploj^ment  of 
antigonococcus  serum  has  not  been  effective,  except  in  chronic  cases. 
Active  immunization  with  killed  cocci  in  epididymitis  and  synovitis 
has  been  successfully  attained  by  Bruck.^^ 

Antibodies  to  Gonococcus. —  The  diagnosis  of  gonorrheal  infection 
of  joints,  of  the  endocardium,  of  the  pleura,  etc.,  has  been  aided  by 
serological  methods.  The  one  most  commonly  employed  consists  in 
making  a  polyvalent  antigen,  using  ten  Torrey  strains  which  are  kept 
in  stock  transplants  on  glucose-ascitic  agar.  The  antigen  is  produced 
on  agar,  using  stock  culture;  after  twenty-four  hours'  growth  the 
cultures  are  scraped  off  and  emulsified  in  neutral,  sterile,  distilled 
water.  The  emulsion  is  autolyzed  one  hour  in  a  water  bath  at  56 °C. 
( 132.8 °F.),  and  heated  for  one  hour  at  80 °C.  (176°F.).  It  is  then 
filtered  through  a  sterile  Berkfeld  filter.  The  filtrate  is  aseptically 
bottled  and  sterilized  three  days  at  56°C.  (132.8°F.),  half  an  hour 
each  day.     It  is  then  made  isotonic  and  is  ready  for  titration. 

BACILLUS  PYOCYANETJS 

Not  infrequently  wound  secretions  are  found  stained  a  green  or 
blue  color  and  emitting  a  peculiar  sweet  odor.  Lueke  (1862)  found 
these  phenomena  to  be  the  result  of  the  presence  of  a  particular 
microorganism,  though  the  excitant  was  obtained  in  pure  culture  by 
Gessard"*  (1882).  The  organism  is  called  the  bacillus  of  blue  or 
green  pus;  however,  the  exudate  itself  is  not  colored,  the  color  being 
developed  by  the  contact  of  the  wound  secretion  with  the  skin  and  the 
dressing  fabric.  If  air  is  excluded  the  color  becomes  yellow  or  dark 
brown. 

Morphology  and  Staining.— Bacillus  pyocj^aneus  is  a  short  rod, 
usually  straight,  at  times  slightl}^  curved,  measuring  (according  to 
Fliigge)  about  one  to  two  microns  in  length  by  about  0.3  of  a  micron 
in  thickness  (Fig.  112).  The  bacilli  usually  appear  singlj',  but  may 
be  arranged  end  to  end  in  short  chains  of  two  or  three.  Spores  have 
not  been  demonstrated.  The  bacilli  are  actively  motile  and  have  a 
flagellum  at  each  end. 

Bacillus  pyocyaneus  stains  with  the  usual  d^'cs  and  decolorizes  with 
Gram. 


212  INFECTIONS  OF  WOUNDS 

Cultivation. —  The  bacillus  pyocyaneus  is  aerobic ;  but  can  be 
adapted  to  anaerobic,  environment.  Under  the  latter  conditions  it 
does  not  produce  its  characteristic  pigmentation.  It  grows  readil}'  on 
the  usual  laboratory  media  of  moderately  alkaline  or  acid  reaction. 
Growth  occurs  at  temperatures  as  low  as  18°C.  (64.4°F.)  to  20°C. 
(68°F.),  more  luxuriantly  at  37.5°C.  (99.5°F.) 

On  agar  slants,  growth  is  abundant  and  confluent,  the  surface  of 
the  agar  being  covered  by  a  moist,  grajdsh,  glistening  layer.  The 
pigment,  which  becomes  visible  after  about  eighteen  hours,  soon  per- 


FiG.   112. —  Bacillus  Pyocyaneus. 

meates  the  medium  and  is  diffused  throughout  it,  giving  the  agar  a 
bright  green  fluorescent  appearance,  which  grows  darker  as  time  goes 
on. 

In  gelatin  stais,  the  flora  spreads  upon  the  surface  more  rapidly 
than  within  the  stab  area,  and  a  liquefaction  of  the  gelatin  takes 
place  causing  a  crater-like  depression  which  gradually'  deepens. 

In  gelatin  plates,  the  colonies  are  round  and  composed  of  a  central 
dense  zone,  which  gradually  merges  into  a  peripheral  granular  area, 
fluid  in  character  and  presenting  a  fringe  of  fine  filaments.  At  first 
the  colonies  are  grayish  yellow,  finally  assuming  a  greenish  hue. 

hi  hroth,  growth  rapidly  forms  a  thin  pellicle,  below  this  there  is  a 
distinct  clouding.  The  pigment  forms  on  top  of  the  fluid.  In  fluid 
media  strong  alkalinity  is  developed. 


PYOGENIC  MICROORGANISMS  213 

The  pigment  would  not  seem  to  have  any  pathological  significance 
(Charrin''^).  It  is  found  in  cultures  as  a  colorless  leukobase  Avhich 
assumes  a  green  color  on  the  addition  of  oxygen.  The  typical  green 
"  pyocyanin  "  (as  the  pigment  is  called)  maj'  be  decolorized  by  re- 
duction substances.  Pyocyanin  may  be  extracted  from  cultures  with 
chloroform  and  crystallized  out  of  such  solution  in  the  form  of  stellate 
crystals  which  have  the  chemical  formula  of  Ci^H.j^N.oO.  (Ledder- 
hose^").  Besides  pyocyanin,  the  bacillus  produces  another  pigment 
which  is  fluorescent  and  iiLsoluble  in  chloroform,  but  soluble  in  water 
iBolaiKP"). 

Pathogenicity. —  Bacillus  pyocyaneus  is  not  a  very  virulent  patho- 
genic bacterium.  It  may  frequently  be  found  as  a  harmless  parasite 
upon  the  skin  and  in  the  upper  respiratory  tract  of  animals  and  men. 
It  does,  however,  at  times  give  rise  to  inflammatory  processes  and  is 
often  present  secondarilj^  to  more  virulent  bacterial  infections.  It 
may  be  responsible  for  primary  infection  when  the  resistance  of  the 
host  is  low  (Rohner^^).  It  has  been  cultivated  out  of  diarrhea  stools, 
and  has  been  found  at  autopsy,  generally'  distributed  throughout  the 
organs  of  children  dead  from  gastro-enteritis  (Neumann'^''). 

Bacillus  pyocj'aneus  has  been  cultivated  from  the  blood  of  patients 
with  bacteremia  (Brill  and  Libman,^*^"  Finkelstein^'^^),  and  from  the 
umbilicus,  in  epidemic  infection  of  the  region  (Wassermaun^'^-). 

Toxins  and  Immunization. —  Filtrates  of  old  bacillus  pyocyaneus 
broth  cultures  contain  a  ferment-like  substance  capable  of  destroj'ing 
some  other  bacteria,  apparently  by  lysis  (Emmerich  and  Low^"^). 
This  substance,  called  "  pyocyanase, "  is  reported  to  protect  animals 
from  anthrax  infection.  Broth  culture  filtrates  evaporated  to  one 
tenth  of  their  volume  in  vacuo  are  used  for  the  purpose  of  removing 
diphtheria  bacilli  from  the  throats  of  convalescent  patients. 

Pyocyanase  is  extremely  thermostabile,  resisting  boiling  for  several 
hours,  and  is  probably  not  identical  with  any  of  the  other  toxins  or 
peptonizing  ferments  produced  by  the  bacillus  pyocyaneus. 

Filtrates  of  old  cultures  are  more  poisonous  to  guinea  pigs  than 
extracts  made  of  dead  bacteria,  which  leads  to  the  conclusion  that  the 
bacteria  produce  both  an  endotoxin  and  a  soluble  secreted  toxin 
("Wassermann"^) .  The  toxin  is  comparatively  thermostabile,  resisting 
100°C.  (212°F.),  for  a  short  time.  Animals  actively  immunized  with 
living  cultures  of  bacillus  pyocyaneus  give  rise  in  their  blood  serum 
to  hacteriolytic  antibodies  only.  Immunized  with  filtrates  from  old 
cultures  their  serum  will  contain  both  bacteriolytic  and  antitoxic  sub- 


214  INFECTIONS  OF  WOUNDS 

stances.  The  true  toxin  of  bacillus  pyocyaneus  never  approaches  in 
strength  that  of  diphtheria  or  of  tetanus.  Specific  agghdinins  have 
been  found  in  immune  serum  (Wassermann^""').  Old  broth  cultures 
of  bacillus  pyocyaneus  contain  a  substance  capable  of  hemolyzing  the 
red  blood  corpuscles  of  dogs,  rabbits,  and  sheep  (Bulloch  and 
Hunter^''*').  This  ^'  yyocyanolusin  "  seems  intimately  attached  to  the 
bacterial  body.  Prolonged  heating  of  cultures  does  not  destroy  it. 
The  filtration  of  young  cultures  yields  very  little  pyocyanolysin.  In 
old  cultures,  however,  a  considerable  amount  passes  with  filtrate. 
Gheorghiewski""  claims  to  have  found  a  leukocyte  destroying  ferment 
in  pyocyaneus  cultures. 

BACILLUS  COLI  COMMUNIS 

This  bacterium  was  found  by  Emmerich  (1884),  in  the  gut  of 
persons  dead  of  cholera,  who  designated  it  as  the  bacillus  neapolitanus. 
V.  Escherich^"^  (1885),  however,  recognized  it  as  normally  inhabiting 
the  intestines  of  nursing  infants;  at  about  the  same  time,  Passet 
isolated  the  microorganism  from  a  perirectal  abscess,  cultivated  it,  and 
gave  it  the  name  of  bacillus  pyogenes  fetidus.  Its  complete  study  is 
credited  to  Buchner"^  (1885). 

Morphology  and  Staining. —  The  bacillus  coli  communis  is  a  short, 
thick  rod  about  one  to  three  microns  in  length  and  about  one  third  to 
one  fifth  its  length  in  thickness  (Fig.  113),  though  at  times  it  takes 
on  a  form  not  unlike  that  of  a  coccus.  The  rods  lie  side  by  side,  but 
may  be  arranged  in  chains  consisting  of  two  or  more  rods.  It  stains 
readily  with  the  usual  aniline  dyes  and  decolorizes  by  Gram's  method. 
It  is  non-sporogenous,  is  motile,  and  has  eight  or  more  peripherally 
arranged  flagella. 

Cultivation. —  The  bacillus  is  aerobic,  capable  of  anaerobic  growth 
under  suitable  cultural  conditions.  It  grows  on  ordinary  laboratory 
media  at  temperatures  varying  from  20°C.  (68°F.)  to  40°C.  (104°F.) 
and  finds  its  optimum  at  about  37.5°C.  (99.5°F.). 

Upon  hroth,  the  bacillus  grows  rapidly,  giving  rise  to  clouding; 
later  to  a  pellicle  and  a  light,  slightly  slimy  sediment.  It  grows 
satisfactorily  on  slightly  acid  and  on  alkaline  media. 

JJpon  agar,  it  forms  grayish  colonies  which  become  visible  within 
twelve  to  eighteen  hours,  rendering  the  medium  progressively  opaque 
as  time  goes  on.  Surface  colonies  at  times  take  an  outline  resembling 
a  grape  leaf. 


PYOGENIC  MICROORGANISMS 


215 


Om  gelatin,  the  colou  bacillus  grows  with  dispatch,  causing  no  lique- 
faction. 

In  peptone  solution,  indol  is  formed. 

In  carbohydrate  broth,  gas  is  formed  in  dextrose,  lactose,  and  man- 
nite,  but  not  in  saccharose.  Levulose,  galactose,  and  maltose  are  also 
fermented  with  the  formation  of  acid  and  gas. 

Cultures  of  the  colon  bacillus  are  characterized  by  a  peculiar  fecal 
odor.  The  acids  formed  by  the  bacillus  from  sugars  are  chiefly  lactic, 
acetic,  and  formic  acids ;  the  gas  C.O.o  and  H.  The  bacillus  grows 
readily  on  media  containing  urine  and  bile. 


-♦  ^ 


Fig.  113. —  Bacillus  Coli  Communis  (Hiss  and  Zinsser). 

Distribution. —  The  colon  bacillus  is  a  constant  inhabitant  of  the 
intestinal  canal  of  human  beings  and  animals.  It  is  found  in  soil,  in 
air,  and  in  milk.  "When  found  in  nature  its  presence  is  regarded  as 
a  contamination  from  human  or  animal  sources. 

In  man,  bacillus  coli  appears  in  the  intestine  soon  after  birth,  at 
about  the  time  of  first  taking  nourishment  (Schild^^°),  and  from  this 
time  on  is  a  constant  inhabitant  of  the  intestinal  tract.  In  the  gut, 
the  bacterial  flora  is  at  its  height  near  the  ileocecal  valve,  diminishing 
in  both  directions  (Gushing  and  Livingood"^).  Under  normal  condi- 
tions it  may  invade  the  portal  circulation,  possibly  being  conveyed  by 
the  leukoc}i:es  during  digestion  (Adami^^^). 


216  INFECTIONS  OF  WOUNDS 

The  question  as  to  whether  the  bacillus  coli  is  concerned  in  aiding 
the  digestion  of  certain  articles  of  diet  is  answered  in  the  negative  by 
the  work  of  Nuttall  and  Thierf elder  ;^^^  however,  Schottelius/^*  work- 
ing with  chickens,  obtained  contrary  results.  It  would  appear  that 
the  bacillus  is  active  in  antagonizing  certain  putrefactive  bacteria  in 
the  gut  (Bienstock""). 

Pathogenicity. —  In  animals  the  pathogenicity  of  the  colon  bacillus 
is  slight  and  varies  with  different  strains.  Intraperitoneal  injec- 
tions of  1  c.cm.  of  broth  culture  cause  death  in  guinea  pigs.  Large 
doses  intravenously  administered  to  rabbits  cause  apyrexia  and  death 
with  symptoms  of  violent  intoxication  within  twenty-four  to  forty- 
eight  hours.  Subcutaneous  inoculation  of  moderate  doses  results  in  a 
localized  abscess.  Poisonous  effects  would  seem  to  be  the  result  of 
toxins  liberated  upon  the  death  of  the  bacteria,  and  not  from  multi- 
plication of  the  bacilli  themselves,  for  often  no  living  organism  can 
be  found  unless  large  doses  have  been  introduced. 

In  man,  the  communis  coli  in  the  gut  achieves  significance  only  in 
the  event  of  pathological  processes  in  this  situation.  In  cases  of 
cholera,  dysentery,  typhoid,  cholera  nostras,  and  simple  enteritis,  the 
diseased  mucosa  is  a  port  of  entrance  for  the  bacilli,  whose  number 
and  virulence  are  increased  under  the  conditions  stated.  When  the 
bacillus  gains  access  to  the  peritoneum,  peritonitis,  bacteremia,  and 
the  formation  of  metastases  occur,  as  is  not  infrequently  the  ease 
following  intestinal  perforation,  or  after  prolonged  strangulation  of 
the  gut.  The  bacillus  is  often  the  cause  of  localized  or  extensive  in- 
flammation of  the  peritoneum  iii  appendicitis  and  in  ischiorectal 
abscesses;  also  of  infection  of  the  biliary  passages,  gall  bladder,  and 
liver;  at  times  it  is  the  excitant  in  cases  of  endocarditis,  pleuritis, 
meningitis,  synovitis,  peritonitis,  etc. 

Although  it  is  a  fair  inference  that  the  bacterium  finds  its  way  into 
the  circulation  from  the  gut,  it  is  also  not  improbable  that  many 
pathological  processes  are  due  to  invasion  of  bacilli  from  the  outer 
world,  as  occurs  in  pancreatitis,  Ijnnphangitis  with  gas  formation, 
otitis  media,  osteomyelitis,  and  infection  of  fresh  wounds. 

Infection  of  the  kidney  may  be  hematogenous  or  due  to  extension 
from  the  bladder.  Severe  general  infection  originated  in  the  genito- 
urinary tract,  and  was  followed  hy  death  in  a  case  reported  by  Sitt- 
mann  and  Barlow,"®  who  succeeded  in  obtaining  pure  cultures  of  the 


PYOGENIC  MICROORGANISMS 


217 


bacillus  coli  in  this  instance.     Puerperal  infection  lias  been  reported 
by  Eisenhart.^^^ 

Toxic  Products. —  The  injection  into  animals  of  gradually  increas- 
ing doses  of  living  or  dead  colon  bacillus  gives  rise  to  specific  bacteri- 
ol3i;ic,  agglutinating,  and  precipitating  substances.  The  injection  of 
any  specific  race  of  colon  bacillus  produces,  in  the  immunized  animal, 
high  agglutination  values  only  for  the  individual  culture  used  for 
immunization,  while  other  strains  of  colon  bacillus  require  much 
higher  concentration  than  does  the  original  strain  (Wolff^^'*).  The 
serum  of  newborn  animals  possesses  no  such  agglutinating  power  as 
does  that  of  the  adult.  The  fact  that  agglutinins  for  the  colon 
bacillus  are  increased  in  the  serum  of  persons  convalescent  from 
typhoid  fever  or  dysentery  can  probably  be  partly  explained  by 
the  invasion  of  the  colon  bacillus,  or  absorption  of  its  products  by 
the  diseased  state  of  the  intestinal  mucosa. 


BACILLUS  TYPHOSUS 

(Bacillus  Typhi  Abdominalis) 
The  bacillus  typhosus,  though  discovered  by  Eberth^^^  (1880),  and 

later  found  in  the  cadaver  by  Koch,  was  first  isolated  in  pure  culture 

by  Gaffkyi--^  (1884). 

Morphology  and  Staining. 
—  The  typhoid  bacillus  is  a 
short  rod  from  1-3.5  microns 
in  length,  with  varying 
widths  of  from  0.5-0.8  mi- 
crons. The  appearance  of 
the  bacillus  is  not  distinc- 
tive, resembling  the  commu- 
nis coli  and  other  bacilli  of 
the  typhoid-colon  group,  ex- 
cept that  it  has  a  general 
tendency  to  greater  slender- 
ness.  Its  ends  are  rounded, 
though  not  club  shaped.  The 
bacillus  does  not  form 
spores,  and  is  actively  mo- 
tile, having  twelve  or  more 

Fig.  114.— Bacillus  Typhosus  (from  twenty-    r,        ^^  -in 

four  hour  culture  on  agar)  (Hiss  and  Zinsser).      Aagella        peripherally       ar- 


218  INFECTIONS  OF  WOUNDS 

ranged  (Fig.  114).     The  bacilli  stain  readily  with  the  usual  aniline 
dyes  and  arc  decolorized  by  Gram's  method. 

Cultivation.—  Bacillus  typhosus  is  easily  cultivated  upon  the  usual 
laboratory  media,  of  either  alkaline  or  acid  reaction.  It  is  aerobic, 
and  facultatively  anaerobic,  in  accordance  with  environment. 

TJpon  agar  plates,  growth  makes  its  appearance  within  eighteen  to 
twenty-four  hours,  as  small  grajish  colonies,  at  first  transparent,  later 
opaque.  There  is  nothing  of  differential  significance  in  the  cultural 
flora. 

In  hroth,  the  bacillus  typhosus  grows  rapidly,  giving  rise  to  diffuse 
clouding,  rarely  to  a  pellicle. 

Upon  gelatin,  the  bacillus  grows  with  great  fertility  and  does  not 
liquefy  the  medium.  In  stahs,  growth  rapidly  lines  the  extent  of  the 
puncture,  and  invades  the  surface  of  the  gelatin  in  a  thin  layer.  In 
gelatm  plates,  fertilization  is  slightly  distinctive  in  character,  appear- 
ing in  twenty-four  hours  as  small,  transparent,  round,  oval,  or,  occa- 
sionally, leaf  shaped  colonies. 

On  potato,  the  growth  of  the  typhoid  bacilli  is  distinctive,  produc- 
ing, in  from  twenty-four  to  forty-eight  hours,  a  barely  discernible 
deposit,  evident  to  the  naked  eye  only  by  a  slight  moist  glistening; 
an  appearance  in  marked  contrast  to  the  grayish-yellow  or  brown 
growth  of  the  colon  bacilli.  If  the  potato  medium  is  rendered  neutral 
or  alkaline,  this  distinction  is  less  manifest. 

In  dextrose,  mannite,  lactose,  and  saccharose  hroth,  the  typhoid< 
bacillus  produces  no  gas.  Tested  for  its  power  to  form  acids  from 
sugars  commonly  used  for  the  purpose  of  differentiation,  the  bacillus 
forms  acid  on  the  monosaccharids,  on  mannite,  maltose  and  dextrin, 
but  not  on  lactose  and  saccharose. 

In  the  Hiss  tube  medium,  the  typhoid  bacillus  produces,  in  from 
eighteen  to  twenty-four  hours,  an  even  clouding  by  virtue  of  its  motil- 
ity, but  does  not  form  gas.  In  contradistinction  to  this,  dysentery 
bacilli  grow  only  along  the  line  of  inoculation,  while  bacilli  of  the 
colon  group  grow  more  often  in  irregular,  skyrocket  like  figures  away 
from  the  stab,  at  the  same  time  breaking  up  the  medium  by  means  of 
gas  bubbles.  Some  actively  motile  colon  bacilli  cloud  the  medium, 
but  the  eruption  caused  by  gas  is  always  evident  (Hiss  and  Zinsser^^). 

Biological  Considerations. —  The  typhoid  bacillus  is  an  aerobic  and 
facultatively  anaerobic  organism,  growing  avidly  both  in  the  presence 
and  in  the  absence  of  oxygen  when  certain  sugars  are  present,  showing 
a  slight  preference,  however,  for  well  aerated  conditions.     It  grows 


PYOGENIC  MICROORGANISMS  219 

most  luxuriantly  at  temperatures  about  37.5°C.  (99.5°F.),  but  con- 
tinues genesis  within  a  range  of  temperature  between  15° C.  (59°F.) 
and  41  °C.  ( 105.8  °F.).  Its  thermal  death  point  is  56 °C.  ( 132.8 °F.) 
in  ten  minutes  (Sternberg*'^).  It  remains  alive  in  artificial  cultures 
for  months  or  even  j^ears,  if  moisture  is  supplied.  In  a  carefully 
sealed  agar  tube,  the  organism  has  survived  for  thirteen  j'ears 
(Hiss^^^).  In  natural  waters  it  may  remain  alive  for  thirty-six  days 
(Klein^--) .  In  ice,  viability  has  lasted  for  three  months  (Prudden^^^) . 
The  bacillus  is  resistant  to  chcmic  influences,  but  is  killed  by  bichlorid 
1 :1000  or  acid  carbolic  5  per  cent  in  five  minutes. 

Pathogenicity. —  In  animals,  the  bacillus  typhosus  does  not  produce 
pathogenesis  analogous  to  typhoid  fever  in  the  human  being.  Injected 
into  the  duodenum  of  guinea  pigs,  the  organism  produces  intestinal 
lesions  and  may  iuvade  the  spleen,  but  the  pathological  picture  is 
unlike  that  of  t^-phoid  fever  (FraenkeP-*).  It  is  probable  that 
typhoid  bacilli  injected  into  animals  do  not  multiply  extensively  and 
that  most  of  the  disturbances  provoked  are  due  to  endotoxins  liberated 
from  the  dead  bacteria ;  this  view  is  corroborated  by  the  fact  that 
inoculation  with  dead  cultures  is  followed  by  essentially  the  same 
manifestation  as  in  inoculation  with  live  cultures  (Petruschky^-"). 
The  intravenous  or  intraperitoneal  injection  of  large  doses  into  rab- 
bits and  guinea  pigs  is  usually  followed  by  shock  and  diarrhea. 
Typhoid  bacilli  injected  into  the  ear  vein  of  a  rabbit  appear  in  the 
bile,  or  may  persist  in  the  gall  bladder  for  weeks  (Welch  and  Blach- 
stein^"®).  Typhoid  bacilli  isolated  from  various  sources  may  evince 
considerable  variations  in  virulence  and  toxicity. 

Typhosus  bacilli  maj'  not  only  remain  latent  for  a  long  time  in  the 
gall-bladder  of  rabbits,  but  ma}^  appear  in  the  blood  with  considerable 
regularit}^  after  the  seventh  or  ninth  day,  and  persist  for  as  long  as 
one  hundred  and  twenty-five  days  (Dorr,^-^  Koch,^^^  Morgan,^-^  and 
Johnson^^"). 

In  man,  most  instances  of  infection  with  the  bacillus  tj^phosus  are 
manifested  by  the  clinical  picture  designated  as  typhoid  fever.  Dur- 
ing the  course  of  the  disease,  and  during  convalescence,  the  bacilli  may 
be  cultivated  from  the  circulating  blood,  the  eruption,  the  feces,  the 
urine,  and  in  exceptional  cases  from  the  sputum.  At  autopsy,  the 
baccilli  may  be  found  also  in  the  lesions  in  the  gut,  and  the  spleen, 
and  often  in  the  liver,  the  kidneys,  and  the  biliary  passages. 

The  disease  in  its  inception  is  a  bacteremia.     It  is  not  unlikely  that 


220      -  INFECTIONS  OF  WOUNDS 

the  intestinal  lesions  are  largely  the  result  of  toxic  products  which  are 
excreted  through  the  intestinal  wall. 

The  bacillus  typhosus  is  present  in  the  circulating  fluid  in  practi- 
cally all  instances  of  infection  with  this  bacterium  (Castellani/^^ 
Schottmiiller^"-).  In  the  stools  their  pres;euce  is  practically'  constant. 
They  have  been  isolated  from  the  stools  of  ambulatory  cases  (Drigalski 
and  Conradi^^^).  The  isolation  of  the  bacilli  from  ambulatory  cases 
is  a  means  of  recognizing  the  so-called  tj'phoid  carriers.  The  technic 
involved  in  this  procedure  is,  however,  an  exceedingly  diiflcult  one, 
though  made  practical  by  the  methods  of  Hiss^^*  and  others. 

Typhoid  hacilli  in  urine  ha\e  been  demonstrated  by  Neumann,^^^ 
Karlinsky,^^®  Petruschky,^^'  Richardson,^^®  Horton-Smith,^^"  Hiss,^^* 
and  others.  They  persist  in  the  urine  for  weeks,  months,  and  years. 
Obstinate  infections  of  the  urinary  passages  are  at  times  the  outcome 
of  the  invasion  of  these  bacteria. 

Typhoid  carriers  and  typhoid  'bacilli  in  the  gall  Madder.  The 
bacillus  typhosus  is  not  infrequently  found  present  in  the  gall  bladder, 
at  operations  for  the  relief  of  cholecA^stitis,  months  and  years  after  the 
occurrence  of  the  typhoid  fever. 

Typhoid  carriers.  About  four  per  cent  of  all  cases  become  chronic 
carriers  (Lentz^^°).  Goldberger,  in  a  compilation  of  the  work  of 
others,  estimates  the  percentage  of  carriers  at  three  per  cent.  This 
would  argue  for  routine  cholecystectomy. 

Suppurative  Lesioxs  Due  to  Typhoid  Bacillus. —  During  typhoid 
convalescence,  suppurative  lesions  occur  in  various  parts  of  the  bod}^, 
the  most  frequent  site  of  lesion  being  the  periosteum  of  the  long  bones, 
and  in  the  joints  (typhoid  arthritis)  (Richardson^^^).  Osteomyelitis 
also  occurs  but  is  comparatively  rare.  Subcutaneous  and  deeply 
located  abscesses  also  occur  (Pratt^^^).  Peritonitis  due  to  the  bacillus, 
without  perforation  of  the  gut,  may  occur  (Zinsser^*^). 

Toxic  Products. —  The  first  work  upon  this  subject  is  credited  to 
Brieger."*  It  is  not  certain  whether  the  toxic  substances  of  typhoid 
bacilli  are,  so-called,  endotoxins,  or  whether  they  are  in  part  composed 
of  soluble  toxins  comparable  to  those  of  diphtheria  and  tetanus; 
following  the  injection  of  which  antitoxic  substances  may  be  found. 
At  this  writing  it  would  seem  that  the  toxic  substances  are  derived 
from  the  cell  body  of  the  bacteria. 

Immunity. —  As  a  rule,  one  attack  of  typhoid  infection  protects 
against  subsequent  ones. 

Animals  may  be  actively  immunized  by  the  injection  of  typhoid 


PYOGENIC  MICROOKGANISMS  221 

bacilli  in  gradually  increasing  doses.  This  active  immunity  is  due  to 
the  presence,  in  the  blood  serum  of  tj-phoid  immune  animals  and  of 
human  bemgs,  of  bacteriolytic,  bactericidal,  and  agglutinating  sub- 
stances, and,  to  a  lesser  extent,  to  precipitins  and  opsonic  bodies. 

The  specific  bactericidal  capacity  of  the  blood  serum  of  artifically 
immunised  animals  is  of  diagnostic  significance  (Pfeififcr^^").  The 
ability  of  the  typhoid  immune  serum  to  arrest  the  motility  of  the 
bacilli  and  cause  their  clumping  (in  vitro)  is  due  to  the  action  of  a 
specific  agglutmin  (WidaP"),  a  phenomenon  of  great  diagnostic  value, 
except  in  persons  who  have  been  vaccinated  against  typhoid. 

The  pathogenicity  of  the  tubercle  and  glanders  bacilli  and  that  of 
the  trichomycete  of  actinomycosis  is  taken  up  under  separate  heads. 

BIBLIOGRAPHY 

1.  RosEXBACH.    ]\Iikroorg.  bei  d.  Wundinfektionskrankheiten  d.  ^Menschen, 

Wiesbaden,  1884. 

2.  LOEB.     Zentrbl.  f .  Bakt.  xxxii,  1902. 

3.  Sternberg.    Text  Book  Bact.  N.  Y.  1901,  p.  375. 

4.  Desloxgchajips.     Paris,  1897. 

5.  Passet.     Berlin,  1885. 

6.  Terin.     Id  Lingelsheim  Aetiol.  d.  Staph.  Inf.  etc.  Wien,  1900. 

7.  Garre.    Beitr.  z.  klin.  Chir.  x,  1893. 

8.  Budixger.     "  Lubarsch  and  Ostertag  Ergebn,  etc.,"  1896. 

9.  ScHiMMELBUSCH.     Same  as  8. 

10.  KoLLE  and  Otto.     Zeitschr.  f.  Hyg*.  Bd.  41,  1902. 

11.  V.  LixGELSHEiM.       same  as  6. 

12.  BoRissow.     "  Zies'Ier's  Beitr."  xvi,  1894. 

13.  Kraus.    Wien  klin.  Woeh.  iii,  1900. 

14.  Neisser  and  Wechsberg.     Zeitschr.  f.  Hyg.  xxxvi,  1901. 

15.  VAX  DE  Velde.     La  Cellule  x,  1894. 

16.  Bail.     Arch.  f.  Hyg.  xxxii,  1898. 

17.  Dexys  et  Van  de  Velde.     La  Cellule  xi,  1895. 

18.  Van  de  Velde.     Press  medic,  i,  1900. 

19.  Richet  and  Hericol'rt.     Compt.  rend  de  I'acad  des  sci.  evil,  1888. 

20.  V.  Lingelsheim.     In  KoIle-Wassei-mann  Handbeh.  d.  path.  Microorg. 

2  Aufl.  Bd.  iv,  1912,  with  lit. 

21.  Beitzky.     Zentrbl.  f.  allg.  Path.  Bd.  15. 

22.  BRrcK,  ]\riCHAELis,  and  Schltltze.    Zeitscbr.  f.  Hx^.  u.  Infkrank.  Bd 

50,  1905. 

23.  RosT  and  Saito.     Deutsch.  Zeitscb.  f.  Cbir.  Bd.  126,  1914. 

24.  Hextschel.     Festschr.  f.  Benno  Schmidt,  Leipzisr,  1896. 

25.  Sciiottmuller.     Zentrbl.  f.  Bakt.  Orig.  Bd.  64,  1912. 

26.  Fehlheisen.     Aetiol.  d.  Ervsip.  Berlin,  1883. 

27.  Petruschky.     Zeitscbr.  f.  Hys".  Bd.  17,  1894. 

28.  Thalmann.     Zentrbl.  f.  Bakt.  1910,  Orig.  Bd.  56. 

29.  Libman.     Med.  Rec.  Ivii,  1900. 

30.  HiSs.     Jour.  Exp.  Med.  vi,  1905. 


222  INFECTIONS  OF  WOUNDS 

31.  Petruschky.     Zeitschr.  f.  Hyg.  Bd.  23,  1896. 

32.  Knorr.     Zeitschr.  f .  Hyg.  xiii. 

33.  Hiss  and  Zinsser.     Textbook  of  Bact.  N.  Y.,  1916. 

34.  Fehleisen.    Quoted  by  Fraenkel,  Zentrbl.  f.  Bakt.  vi. 

35.  Marbaix.     La  Cellule,  1892. . 

36.  Van  de  Velde.     Monatschrift  prakt.  Thierheilke,  ii. 

37.  KuTSCHER.     Zentrbl.  f.  Bakt.  xlvi. 

38.  Jehle.     Jahr.  b.  d.  Kinderheilkunde,  Bd.  65,  1907. 

39.  Marmorek.     Berlin.  Klin.  Wocli.,  1902. 

40.  Baginsky.     Berlin.  Klin.  Woch.,  1900. 

41.  V.  LiNGELSiiEiM.     Same  as  No.  20. 

42.  Marmorek.     Ann.  d.  I'inst.  Pasteur,  1895. 

43.  ScHOTTMiJLLER.    Miinch.  med.  Woch.,  1903. 

44.  Besredka.     Ann.  de  I'inst.  Pasteur  xv,  1901. 

45.  Schlesinger.     Zeitschr.  f.  Hyg.  xxiv,  1903. 

,  46.  Koch  and  Petruschky.    Zeitschr.  f .  Hyg.  xxiii,  1896. 

'  47.  Zangemeister.     Monatschr.  f.  Geburtshilfe  u.  Gyn.  Bd.  26, 1907. 

48.  Van  de  Velde.     Arch,  de  med.  exper.  1897. 

49.  Denys.     Le  Serum  antistrept.  Louvain,  1896. 

50.  Aronson.     Berlin  Klin.  Woch.  xxxii,  1896. 

51.  Hiss.     Jr.  Med.  Research  xix,  1908. 

52.  WiNSLOW  and  Palmer.     Jr.  of  Inf.  Dis.  No.  viii. 

53.  Aronson.     Berlin.  Klin.  Woch.  1902,  xliii. 

54.  A.  Fraenkel.     Zeitschr.  f.  klin.  Med.  x,  1886. 

55.  Weichselbaum.     Med.  Jahrbchr.  Wien.,  1886. 

56.  Pasteur.     Bull,  de  I'acad.  de  med.,  1881. 

57.  Welch.     Johns  Hopkins  Bull,  xiii,  1892. 

58.  Hiss.    Jr.  Exp.  Med.  vi,  1905. 

59.  Guarnieri.     Att.  della  R.  Acad,  di  Roma  iv,  1888. 

60.  Bordoni-Ufpreduzzi.     Arch.  p.  1.  sc.  med.  xv,  1891. 

61.  Sternberg.     Zentrbl.  f .  Bakt.  xii,  1891. 

62.  Wadsworth.     Jr.  Inf.  Dis.  iii,  1906. 

63.  Green.    Zentrbl.  f.  Bakt.  Bd.  30,  1901. 

64.  .  de  Quervain.    Korresp.  fiir  Schweizer  Aerzte,  1902. 

65.  Jensen.     Arch.  f.  klin.  Chir.  Bd.  70,  1903. 

66.  Klemperer.     Berlin,  klin.  Woch.  xxxiv-xxxv,  1891. 

67.  Mennes.     Zeitschr.  f.  Hyg.  xxv,  1898. 

68.  Pane.     Rif.  med.  xxi,  1898. 

69.  FOA  and  Carbone.     Zentrbl.  f.  Bakt.  x,  1899. 

70.  Macfayden.     Brit.  Med.  Jr.  ii,  1906. 

71.  Cole.     Harvey  Lect.  N.  Y.,  1913. 

72.  Neufeld.     Zeitschr.  f.  Hyg.  xi,  1902. 

73.  DocHEz  and  Gillespie.     Jr.  A.  M.  A.  1913,  Ixi.  727. 

74.  DocHEZ  and  Avery,     Jr.  Exp.  Med.  1915,  xxi.  114. 

75.  Neufeld  and  Rimpau.     Deutsch.  med.  Woch.,  1904. 

76.  Gaffky.     Mitteil.  a.  d.  kais.  Gesundheitsamt  i,  1881. 

77.  MiJLLER.    Wien  klin.  Woch.,  17,  1904. 

78.  Bezan^on.     Semaine  med.,  1898. 

79.  FoRNEACA.     Rif.  med.,  1903. 

80.  Neisser.    Zentrbl.  f.  d.  med.  Wiss.,  1879. 

81.  Bumm.     ''  Beitr.  z.  Kenntniss  des  Gonococeus  "  Wiesbaden,  1885. 

82.  SCHOLTZ.     Arch.  f.  Dermat.,  1899. 

83.  Wertheim.    Arch.  f.  Gyn.,  1892. 


PYOGENIC  MICROORGANISMS  223 

84.  Teague  and  Torrey.     Jr.  Med.  Research,  Dec.  1307,  xvii. 

85.  Heiman.     Med.  Rec,  1896. 

86.  NicOLAYSEN.     Fort.  d.  Med.  xxi,  1897. 

87.  Heymaxn.     Deutsch.  med.  Woch.,  1909. 

88.  HOLMBERG.     Zentrbl.  f.  Chir.,  1909. 

89.  Ullmaxx.     "Wien.  med.  Presse,  1900. 

90.  CoLOMBixi.     Zentrbl.  f.  Bakt.  Bd.  24,  1898. 

91.  NicoLAYSEX.    Zentrbl.  f.  Bakt.  Bd.  22,  1897. 

92.  DE  Christmas.     Ann.  de  I'inst.  Pasteur,  1900. 

93.  Bruck.     Miinch.  Woch.,  1913,  No.  22. 

94.  Gessard.     These  de  Paris,  1882. 

95.  Charrix.     "  La  maladie  pyocyanique,"  Paris,  1889. 

96.  Ledderhose.     Quoted  from  Boland,  Zentrbl.  f.  Bakt.  xxv,  1889. 

97.  BOLAXD.     Same  as  96. 

98.  ROHXER.     Zentrbl.  f.  Bakt.  xi,  1892. 

99.  Neumaxx.     Jahrb.  f.  Kinderheilk,  1890. 

100.  Brill  and  Libmax.     Amer.  Jr.  Med.  Sci.,  1899. 

101.  Fixkelsteix.     Zentrbl.  f.  Bakt.,  1899. 

102.  Wasserjiaxx^.     Virchow's  Arch.  cLxv,  1901. 

103.  Emmerich  and  Low.     Zentrbl.  f.  Bakt.  Orig.  Bd.  49,  1909. 

104.  Wassermaxx.     Zeitschr.  f.  Hyg.  xxii,  1896. 

105.  Wassermaxx.     Zeitschr.  f.  Hyg.,  1902. 

106.  Bulloch  v.  Huxter.    Zentrbl.  f.  Bakt.  xx\^iii,  1900. 

107.  Gheorghiewski.     Ann.  de  I'inst.  Pasteur,  xiii,  1899. 

108.  Escherich.     "  Die   Dannbakt.    des    Saiiglings,"    Stuttgart,    1886,    and 

Zentrbl.  f.  Chir.  Bd.  i,  1887. 

]  09.  Buchxer.     Arch,  f .  Hyg.,  3,  1885. 

110.  Schild.     Zeitschr.  f.  Hyg.  xix,  1895. 

ni.  Cushixg  and  Livixgood.     Johns  Hopkins  Press,  1900. 

112.  Adami.     Jr.  A.  M.  A.  Dec,  1899. 

113.  Nuttall  u.  Thierfelder.     Zeitschr.  f.  Physiol.  Chemie  xxi,  xxii, 

114.  Schottelius.     Arch.  f.  Hyg.  xxxiv,  1889. 

115.  BiEXSTOCK.     Arch.  f.  Hyg.  xxxix,  1901. 

116.  SiTTMAXx  and  Barlow.     Deutsch.  Arch.  f.  klin.  Med.  Bd.  52,  1894. 

117.  Eisexhart.     Arch.  f.  Gyn.  Bd.  47,  1894. 

118.  Wolff.    Zentrbl.  f.  Bakt.  xxv,  1899. 

119.  Eberth.     Virch.  Arch.  81,  1880,  and  1881,  No.  83. 

120.  Gaffky.     Mit.  a.  d.  kais.  Gesundheitsamt,  2,  1884. 

121.  Hiss.    Exp.  Med.  ii,  1897. 

122.  Klein.     Med.  Officers'  Report,  Local  Govern.  Bd.,  London,  1894. 

123.  Pruddex.     Med.  Record,  1887. 

124.  Fraexkel.     Zentrbl.  f.  klin.  :\Ied.  x,  1886. 

125.  Petruschky.     Zeitschr.  f.  Hyg.  xii,  1892. 

126.  Welch  and  Blaciisteix.     Bull.  Johns  Hopkins  Hosp.  ii,  1891. 

127.  Dorr.    Zentrbl.  f.  Bakt.,  1905. 

128.  Koch.     Zeitschr.  f.  Hvg.,  1909. 

129.  Morgax.     Jour,  of  Hyg.,  1911. 

130.  Johnsox.     Jr.  of  Med.  Research,  xxvii,  1912. 
1.31.  Castellaxi.     Rif.  Med.,  1900. 

132.  Schottmuller.    Deutsch.  med.  Woch.  xxxii,  1900. 

133.  Drigalski  and  Coxradi.     Zeitschr.  f.  Hyg.  xxxix.  1902. 
334.  Hiss.     Med.  News,  Mav,  1901. 

135.  Neumaxx.     Berbn    klin.  Woch.  xxvii,  1890. 


224  INFECTIONS  OF  WOUNDS 

136.  Karlikskt.     Prag.  med.  Woch.  xv,  1890. 

137.  Petruschky.     Zentrbl.  f.  Hyg.  xxiii,  1898. 

138.  Richardson.     Jr.  Exp.  Med.  iii,  1898. 

139.  Horton-Smith.     Lancet,  May,  1899. 

140.  Lentz.     Hyg.  Rundschau  xvi,  1906. 

141.  Richardson.     Jr.  Boston  Soc.  Med.  Sci.  No.  5.  1900, 

142.  Pratt.     Jr.  Boston  Soc.  Med.  Sci.  iii,  1899. 

143.  Zinsser.     Proe.  N.  Y.  Pat.  Soc,  1907. 

144.  Brieger.     Deutsch.  med.  Woch.  xxvii,  1902. 

145.  Pfeipfer.     Deutsch.  med.  Woch.  xlviii,  1894. 

146.  WiDAL.     Bull,  de  la  soc.  med.  des  Hop.  vi,  1896. 


CHAPTER  VII 

ii;XAMINATIOM   OF   BLOOD  AXD   WOUND   SECEETIOXS,  ETC.,  IN 
CONNECTION  WITH  SUKGICAL  INFECTIONS 

EXAMINATION  OF  BLOOD 

In  surgical  infections  the  modifications  in  the  relative  quantities  of 
the  various  constituents  of  the  blood  are  of  considerable  diagnostic  and 
prognostic  value.  The  examination  of  the  blood  for  the  detection  of 
invading  disturbing  elements  (bacteria,  parasites,  etc.)  is  of  equal 
import,  and  as  infection  of  the  wound  or  of  the  untraumatized  parts, 
organs,  and  tissues  of  the  hody  often  takes  place  without  invasion  of 
the  circulatory  fluid  (local  infections),  the  examination,  by  various 
means,  of  exudates  may  also  be  regarded  as  a  measure  of  much  value. 

As  the  technic  employed  in  this  connection  is  taken  up  in  extenso 
in  special  works  pertaining  to  the  subject,  this  presentation  is  to  be 
regarded  as  only  accentuating  the  value  of  the  application  of  labora- 
tory findings  as  to  the  clinical  problems  met  by  the  surgeon. 

The  Red  Blood  Corpuscles  average  about  5,000,000  to  the  c.mm.  in 
men  and  about  4,500,000  in  women.  Lessening  of  their  number  per 
cmm.  is  significant  chiefly  in  connection  with  bleeding  during  opera- 
tions and  loss  of  blood  as  the  result  of  injur}''.  "When  making  a  quan- 
titive  estimate  of  the  red  blood  corpuscles  in  the  blood,  it  is  also 
advisable  to  determine  the  percentage  of  coloring  matter  present. 
Blood  containing  half  the  normal  amount  of  coloring  matter  is  said 
to  contain  50  per  cent  of  hemoglobin.  The  color  index  of  a  given 
specimen  is  indicated  by  dividing  the  percentage  of  coloring  matter 
by  the  number  of  corpuscles  expressed  as  a  percentage  of  the  normal. 
For  example ;  the  normal  number  of  red  corpuscles  is  5,000,000,  the 
hemoglobin  100  per  cent,  so  that  the  color  index  is  100/100=1.  If  the 
corpuscles  fall  to  3,000.000  per  c.mm.  (60  per  cent  of  the  normal), 
and  the  hemoglobin  be  reduced  to  30  per  cent,  the  color  index  is 
30/60=0.5 ;  i.  e.,  each  corpuscle  contains  only  half  the  normal  amount 
of  coloring  matter. 

Following  severe  hemorrhage  the  ({uantit}'  of  blood  present  in  the 

225 


226  INFECTIONS  OF  WOUNDS 

body  is  reduced,  yet  the  percentage  of  its  elements  is  unaltered.  In 
a  short  time  the  normal  quantity  is  reestablished  (absorption  of 
fluids),  but  the  proportion  of  red  corpuscles  and  hemoglobin  is  sym- 
metrically lessened  so  that  the  color  index  remains  normal.  There  is 
also  a  temporary  leukocytosis.  The  quantity  of  circulating  fluid  may 
be  enhanced  by  the  infusion  of  saline  solution,  thus  limiting  the 
extracting  of  fluids  from  the  tissues,  accelerating  the  regeneration  of 
the  cellular  elements  of  the  blood,  and  raising  the  blood  pressure  (see 
shock). 

Regeneration  of  red  Mood  corpuscles  occurs  more  rapidly  than  does 
that  of  hemoglobin,  so  the  color  index  falls.  The  time  required  for 
full  regeneration  varies,  being  more  rapid  in  men  than  in  women,  and 
in  young  adults  than  in  old  or  young  persons.  About  one  per  cent  of 
hemoglobin  is  regenerated  per  diem,  the  blood,  after  a  loss  of  twenty 
per  cent  hemoglobin,  becoming  normal  in  about  twenty  days. 

In  acute  putrefactive  infection,  and  in  pyogenic  bacteremia,  a 
menacing  anemia  occurs,  the  various  constituents  of  the  blood  under- 
going rapid  degeneration  and  the  hemoglobin  being  destroyed  more 
quickly  than  the  corpuscles. 

The  Leukocytes  are  very  important  cellular  elements  from  a  sur- 
gical standpoint.  The  total  number  per  cmm.,  and  a  differential 
count  of  the  various  kinds  of  cells,  is  of  great  diagnostic  significance. 
The  total  count  is  made  on  thin  films  of  blood  stained  in  various  ways. 

In  Health  the  blood  contains  from  4,000  to  10,000  leukocytes  per 
cmm.,  five  different  forms  of  the  cell  being  present, —  the  polynuclear 
leukocyte,  the  eosinophile  leukocyte,  the  mast-cell,  the  lymphocyte, 
and  the  hyaline  cell ;  of  these,  the  first  three  contain  granules,  the 
others  do  not.  The  subsequent  description  is  based  on  the  employment 
of  the  Jenner  Staining  Method.^ 

1.  The  polynuclear  or  polymorphonuclear  leukocyte  (Fig.  115) 
is  larger  than  a  red  corpuscle,  and  has  a  deformed  or  dentated 
nucleus  which  may  appear  to  be  multiple,  but,  when  successfully 
stained,  is  shown  to  have  its  segments  connected  by  fine  filaments.  Its 
protoplasm  is  finely  granular  and  has  an  affinity  for  acid  stains. 

The  polynuclear  leukocytes  are  the  chief  phagocj^tic  cells  of  the 
blood,  are  actively  ameboid,  endowed  with  the  power  of  ingesting 
bacteria,  and  capable  of  engulfing  small  particles  of  tissue  detritus. 
They  originate  in  the  bone  marrow  and  constitute,  normally,  from  65 
to  75  per  cent  of  all  the  leukocytes. 

2.  The  eosinophile  leukocytes  (Fig.  115)  are  about  the  same  size 


BLOOD  AND  WOUND  SECRETIONS,  ETC. 


227 


as  the  polynuclcar,  and  have   a  bilobed   or  polymorphous   nucleus. 
The  granular  appearance  of  their  protoplasm  is  clearly  defined. 

The  eosmophiles  form  from  2  to  4  per  cent  of  the  leukocytes  in 
normal  blood  and  originate  in  part  in  the  bone  marrow  and  in  part  in 
connective  tissue  in  other  portions  of  the  body.  They  are  feebly 
motile  and  their  function  is  unknown. 

3.  The  mast-cells  (Fig.  115)  have  lobulated  nuclei  and  contain 
granules.  They  are  present  in  a  small  proportion  (i/^  per  cent)  in 
normal  blood,  originate  in  connective  tissue,  and  are  often  present  in 
considerable  numbers  in  inflamed  tissue.     Their  function  is  unknown. 

4.  The  lymphocytes  (Fig.  115)  are  devoid  of  granules  and  their 

nuclei  are  not 
polym  o  r  p  h  o  us. 
The}'  vary  in  size 
and  are  somewhat 
smaller  than  the 
red  corpuscle. 
Each  lymphocyte 
has  a  single  circu- 
lar nucleus  im- 
bedded in  a  nar- 
row zone  of  pro- 
toplasm. I  n 
health,  lympho- 
cytes     constitute 

Fig.  115. —  Corpusculae  Elements  of  Normal  Blood.       20  to  25  per  cent 

a,  Red  blood  corpuscles;  6,  polynuelear  leukocyte;  e,  Qf  -(^j^g  leukoc'V'tes. 
eosinophile;   d,  mast  cell;   e,  hyaline  or  large  multinuclear  .    . 

cell;  /,  lymphocyte.  They  originate  m 

the  IjTnphatic 
glands,  spleen,  Peyer's  patches,  and  lymphadenoid  tissue.  They  are 
probably  identical  with  *'the  small  round  cell"  found  in  inflamma- 
tory processes,  and,  according  to  Ribbert,^  are  concerned  in  the  ab- 
sorption of  certain  products  of  inflammation. 

5.  The  large  hyaline  or  mononuclear  cells  (Fig.  115)  are  mark- 
edly larger  than  the  red  corpuscles.  They  have  a  single,  circular, 
oval,  or  kidney  shaped  nucleus  which  is  smaller  relatively  to  the  cell 
than  obtains  with  the  Ijinphocytes.  The  protoplasm  is  devoid  of 
granules.  These  cells  form  2  to  4  per  cent  of  the  leukocytes  of  normal 
blood  and  possess  phagocytic  function.  Their  origin  is  unknown,  but 
they  are  believed  to  originate  from  the  endothelial  lining  of  vessels. 


b                  C 

i-  =,-  '  n 

WW 

• 

^^m^'iP 

228  INFECTIONS  OF  WOUNDS 

Ax   INCREASE   ABOVE    THE    NORMAL    OF   LEUKOCYTES    PRESENT    IN    THE 

PLOOD  IS  TERMED  LEUKOCYTOSIS.  Under  most  conditions  this  is  due  to 
an  increase  in  the  proportion  of  polynuclear  cells ;  special  terms  are 
used  for  other  forms  of  leukocj'tes ;  an  increase  in  the  eosinophils  is 
called  eosinophilia,  and  an  increase  in  the  lymphocytes  is  called 
IjTnphocytosis.  A  dimimition  of  the  leukocytes  is  called  leukopenia. 
Leukocytosis. —  The  increased  proportion  of  leukocytes  in  the  blood 
during  digestion,  in  the  newborn,  and  in  pregnant  women,  is  physio- 
logical, and  must  be  taken  into  account  in  interpreting  the  "blood 
picture"  in  a  diagnostic  sense. 

Pathological  leukocytosis  occurs  in  a  large  variety  of  infectious 
processes  and  becomes  most  dominantly  manifest  in  the  presence  of 
suppuration.  In  appendicitis,  leukoc}i:osis  may  be  regarded  as  the 
most  valuable  single  sign  indicative  of  the  character  of  the  process 
present.  In  the  absence  of  purulent  exudate  the  blood  shows  slight 
leukocytosis  (about  15,000  per  c.mm.)  ;  when  pus  is  present  the  num- 
ber of  cells  rises  to  from  30,000  to  50,000  per  c.mm.  For  practical 
purposes  a  specimen  of  blood  showmg  20,000  leukocytes  may  be 
regarded  as  indicative  of  a  suppurative  inflammation,  provided,  of 
course,  that  other  causes  for  the  increase  are  excluded.  A  leukocyte 
count  of  from  15,000  to  20,000  is  not  determining;  however,  if  this 
proportion  persists  for  several  days,  it  is  justifiable  to  assume  the 
existence  of  a  low  grade  of  purulent  inflammation  (coli  communis). 
A  high  leukocyte  count  is  not  indicative  of  the  size  of  an  abscess,  but, 
when  it  occurs  early  in  the  course  of  an  infection,  it  may  be  looked 
upon  as  expressive  of  the  resistance  of  the  host,  or  of  the  virulence  of 
the  invading  process. 

Kemoval  of  pus,  or  ablation  of  the  part  involved,  is  promptly  fol- 
lowed (twelve  hours)  hy  a  fall  in  the  numl>er  of  leukocytes.  If  leuko- 
cji:osis  persists,  secondary  involvement  Ls  to  be  looked  for. 

The  absence  of  leukocytosis  indicates  that  the  process  under  con- 
sideration is  not  attended  with  suppuration ;  however,  this  conclusion 
is  not  inevitable ;  in  practice,  other  factors  must  be  taken  into  account. 
Leukocytosis  occurs  in  response  to  the  entrance  into  the  blood  of 
bacterial  toxins,  where  they  exert  a  positive  chemotaxic  action,  attract- 
ing the  leukocytes,  and  at  the  same  time  stimulating  the  bone  marrow 
to  an  increased  production  of  leukocytes.  While  the  purulent  exudate 
is  retained,  the  toxins  gain  access  to  the  circulating  fluid;  when,  how- 
ever, drainage  is  established,  the  toxins  are  expelled  and  leukocytosis 


BLOOD  AND  WOUND  SECRETIONS,  ETC.  229 

falls,  even  though  the  actual  purulent  inflammatory  process  does  not 
immediately  subside. 

When  the  pyogenic  l)acteria  have  heen  killed,  the  toxins  are  elim- 
inated from  the  blood  stream,  and  leukocj'tosis  falls,  although  there 
may  still  be  purulent  exudate  present  in  the  tissues,  i.  e.,  a  high  leuko- 
cytosis is  indicative  of  pyogenic  infection  rather  than  evidence  of  the 
presence  of  pus.  The  existence  of  sterile  pus  in  quiescent  pyosalpinx 
does  not  provoke  leukocytosis,  but  an  acute  exacerbation  of  the  process 
is  immediately  attended  with  a  blood  picture  expressive  of  acute 
suppurative  inflammation. 

Virulent  infections,  and  those  invading  a  feeble  host,  may  not  be 
characterized  by  leukocytosis  nor  by  leukopenia.  General  and  local 
leukocytosis  is  indicative  of  resistance,  and  its  absence,  in  the  presence 
of  suppurative  processes,  may  be  regarded  as  of  unfavorable  prog- 
nostic significance. 

Chronic  or  cold  abscesses  are  not  attended  with  leukocji:osis.  The 
toxins  resulting  from  these  lesions  do  not  provoke  positive  chemotaxis 
(activity  of  the  polynuclear  leukocytes).  The  lymphocji:es  are 
increased  in  number  at  the  site  of  lesions  of  this  kind,  though  the 
lymphoc3'tes  in  the  blood  may  not  be  increased,  a  phenomenon 
explained  on  the  ground  that  their  lack  of  motility  renders  them  less 
responsive  to  chemotactic  lure. 

The  appearance  in  the  blood  of  leukocytes  whose  protoplasm  con- 
tains small  granules  of  ghjcogen  is  regarded  as  indicating  the  occur- 
rence of  suppuration,  or  at  least  the  invasion  of  pyogenic  bacteria. 
The  test  is  not  infallible  and  may  be  considered  as  only  mildly 
corroborative. 

Massive  leukocytosis  also  occurs  in  diphtheria,  plague,  and  pertus- 
sis. In  rheumatic  fever,  lues,  and  gonorrhea  there  is  moderate  leuko- 
cytosis ;  and  in  typhoid  fever,  influenza,  measles  and  malaria  no 
increase  in  leukocytes  occurs,  leukopenia  being  not  unusual. 

Pathological  leukocytosis  also  occurs  after  severe  bleeding,  and  in 
all  cachectic  conditions,  especially  in  that  due  to  malignant  disease, 
in  which  instance  it  is  a  result  of  the  reactive  inflammation  caused  by 
the  neoplasm.  In  carcinoma  of  the  stomach,  the  absence  of  digestive 
leukocj^tosis  is  to  be  taken  into  account.  The  corpuscular  count  should 
be  made  first  during  fasting  and  repeated  several  times  at  hourly 
intervals  after  meat  is  ingested.  If  the  leukocytes  do  not  increase  in 
number  it  is  fair  to-  assume  that  gastric  digestion  is  gravely  lessened  — 
perhaps  the  result  of  malignant  disease. 


230 


INFECTIONS  OF  WOUNDS 


Lymphocytosis  or  an  increase  in  the  lymphocytes  may  be  absolute 
or  relative.  A  relative  increase  (in  which  the  percentage  is  more 
than  25,  although  the  total  number  of  leukoc^'tcs  does  not  exceed  the 
normal)  occurs  in  typhoid  fever,  tuberculosis,  and  malaria.  A  great 
excess  of  leukocytes  (150,000  or  more  per  c.mm.),  the  majority  being 
IjTuphocytes,  occurs  only  in  Ij'mphatic  leukocythemia,  an  important 
differential  diagnostic  factor  between  this  and  Hodgkin's  'disease,  in 
which  latter  the  leukocytes  are  normal  or  only  slightly  increased  in 
number.  Children's  blood  contains  a  large  proportion  of  h'mpho- 
cytes,  reaching  60  per  cent,  and  in  inflammatory  diseases  of  children, 
the  increase  of  leukocytes  may  be  represented  in  the  form  of  Ij^Tnpho- 
cytes,  and  not  of  the  polynuclear  cells  alone.  This  is  especially  true 
in  instances  of  l^'mph  node  infection. 

Eosinophilia  (a  relative  increase  of  the  eosinophiles)  occurs  in  :  (1) 
Infections  with  parasites  (trichinosis,  hydatid)  ;  (2)  some  skin  dis- 
eases;   (3)  bronchial  asthma;    (4)  gonorrhea. 

Phagocytosis  is  pathological  leukocytosis.  The  part  that  these  cel- 
lular elements  play  in  combating  infection  and  in  the  absorption  of 
foreign  substances,  etc.,  has  already  been  taken  up  (p.  8,  p.  174). 

The  report  of  a  typical  pathological,  so-called,  "blood  count,"  as 
compared  to  normal  findings,  furnishing  the  data  required  for  prac- 
tical clinical  purposes  may  be  compiled  as  follows : 


SUPPURATION- 

KORMAL  BLOOD 

ACUTE    APPEXDICITIS 

Red   corpuscles    5,120,000  per  c.mm. 

4,500,000  per  c.mm. 

Hemoglobin 100  % 

85         % 

Color  index 

1. 

0.95  % 

■  No    abnormal   forms 

seen. 

Morphology    of    red 

Corpuscles     uniform 

Normal 

corijuscles. 

in   size,   and   stain 
only      with      acid 
stain  (eosin). 

Leukocytes ""....    7,000  per  c.mm. 

23,000  per  c.mm. 

Polynuclears 72       %  . 

86.2  % 

Lymphoc}i;es 22.8  % 

11.6  % 

Eosinophiles 2.4% 

1.0  % 

Large  hvalines   2.4% 

1.2  % 

Mast  ceils   G  4  9^ 

No  at 

No  other  forms  of  leukocytes  seen. 

)normal  forms  seen. 

Some 

of    the    polynuclears 

show 

glycogenic     degenera- 

tion. 

BLOOD  AND  WOUND  SECRETIONS,  ETC.  231 

BACTERIAL  EXAMINATIONS  OF  MATERIAL  FROM  PATIENTS 

In  obtaining  specimens  for  bacterial  examination,  the  diagnostic 
value  of  the  result  is  dependent  upon  the  technic  employed  in  obtain- 
ing the  material  from  the  patient. 

Specimens  collected  at  the  bedside,  or  in  the  operating  room,  should 
be  transferred  directly  to  the  proper  media  or  else  into  test  tubes  and 
so  conveyed  to  the  laboratory. 

SjTinges,  when  used  for  the  collection  of  blood  or  exudates,  should 
be  so  constructed  as  to  permit  of  sterilization  by  dry  heat  or  boiling. 
Instruments  sterilized  by  chemicals  should  be  avoided  for  obvious 
reasons.  Fluids  should  be  collected  directly  into  sterilized  centrifuge 
tubes  to  lessen  the  danger  of  accidental  contamination  consequent  to 
repeated  manipulation. 

Examination  of  Exudate. —  Pus  should  at  first  be  examined  morpho- 
logically b}^  some  simple  stain,  such  as  gentian-violet,  and  by  the  Gram 
method.  Specimens  should  also  be  stained  by  Jenner's  method  to 
show  the  relationship  of  the  bacteria  to  the  cells.  Such  morphological 
examination  furnishes  a  guide  to  further  manipulations,  and  supplies 
a  control  for  the  results  obtained  in  cultural  differentiation.  The 
specimens  are  then  transferred  to  the  proper  media,  and  cultured  on 
pour  plates,  agar,  serum,  etc. 

The  colonies  which  develop  on  the  medium  employed  are  subjected 
to  microscopical  examination  for  identification.  In  some  instances,  it 
is  also  necessary  to  subject  the  bacterial  flora  to  inoculation  and  agglu- 
tination before  a  conclusion  as  to  the  identity  of  the  offending  patho- 
logical aggressor  can  be  established. 

Peritoneal,  pericardial,  pleural  o-r  spinal  exudates  should  be  cen- 
trifuged  before  examination.  A  differential  count  of  the  cellular 
content  is  advantageous.  Morphological  and  cultural  examinations 
are  made  in  the  manner  described  in  connection  with  pus. 

The  exudates  derived  from  these  sources  are  very  similar  in  char- 
acter to  those  obtainable  in  other  portions  of  the  body,  and  may, 
perhaps,  be  considered  as  likely  to  contain  tubercle  bacilli.  This 
makes  inoculation  tests  quite  necessary. 

Spinal  Fluid. —  Spinal  fluid  should  invariably  be  centrifuged.  The 
meningococcus,  pneumococcus,  and  the  streptococcus  are  the  bacteria 
most  frequentl}^  found  in  spinal  fluid,  though,  most  of  the  various 
bacteria  are  more  or  less  frequently  found.     Failure  to  locate  organ- 


232  INFECTIONS  OF  WOUNDS 

isms  morphologically  is  not  determining,  and  should  be  followed  by 
cultivation  tests. 

Examination  of  Urine. —  Examination  of  urine  for  bacteria  is  of 
value  only  when  the  specimen  is  obtained  with  sterile  apparatus,  and 
other  sources  of  accidental  contamination  eliminated.  The  urine 
should  be  centrifuged,  the  sediment  examined  morphologically  and 
cultivated  on  suitable  media.  Animal  inoculation  tests  are  frequently 
necessary.  The  bacillus  smcgmatis  must  be  differentiated  from  the 
tubercle  bacillus. 

Examination  of  Feces. —  Human  feces  contain  enormous  quantities 
of  bacteria  of  many  varieties.  Klein^  estimates  that  there  are  about 
75,000,000  bacteria  is  one  milligram  of  feces.  Large  as  the  number 
morphologically  demonstrable  is,  only  a  meager  colonial  flora  is  obtain- 
able. This  is  explicable  on  the  ground  that  special  culture  media  are 
necessary  for  many  of  the  species  found,  and  that  many  of  the 
bacteria  present  in  the  morphological  specimen  are  dead.  This  would 
indicate  that  bactericidal  processes  occur  in  the  gut,  possibly  through 
the  agency  of  intestinal  secretions,  bile,  and  the  action  of  the  products" 
of  metabolism  of  the  hardier  races  present  (Hiss  and  Zinsser*).  The 
greater  part  of  the  intestinal  flora  consists  of  the  bacilli  of  the  lactis 
aerogenes  grouj^,  bacillus  f ecalis  alcaligenes,  bacillus  mesentericus,  and 
relatively  smaller  numbers  of  streptococci,  staphylococci,  and  Gram- 
positive  anaerobics.  Many  other  species,  not  necessarily  of  patho- 
logical significance,  may  be  present.  Herter^  suggests  that  the  pres- 
ence of  the  bacillus  aerogenes  capsulatus  in  the  gut  may  stand  in  a 
causative  relationship  to  pernicious  anemia. 

Bacterial  examination  of  feces  is  most  frequently  undertaken  to 
determine  the  presence  of  bacillus  typhosus,  although  this  is  accom- 
plished only  with  difficulty,  owing  chieflj^  to  the  confusion  caused  by 
the  presence  of  the  communis  coli. 

Cholera  spirilla  may  be  recognized  by  morphological  examination. 
Examination  for  the  dysentery  bacilli  is  unsatisfactory^ ;  that  for  the 
tubercle  bacilli  is  difficult  and  of  questionable  significance. 

Blood  Cultures. —  The  diagnosis  of  bacteremia  rests  on  the  isolation 
of  bacteria  from  the  blood.  The  examination  is  of  value  if  the  technic 
is  properly  executed.  Improvement  in  technic  has  increased  the 
number  of  positive  findings.  In  scarlatina,  streptococcemia  has  been 
demonstrated  by  Hektoen,®  Jochmann,'^  and  others.  Baginsky  and 
Sommerfeld^  demonstrated  the  presence  of  streptococci  in  eighty-two 
cases  of  the  same  disease.     In  lobar  pneumonitis,  pneumococci  havQ 


BLOOD  AND  WOUND  SECRETIONS,  ETC.  233 

been  demonstrated  in  the  blood  by  Badnel,^  Prochaska/°  Rosenow/^ 
and  others.  In  typhoid  fever,  the  bacillus  typhosus  has  been  culti- 
vated in  about  80  per  cent  of  their  cases,  by  Cole,^-  Schottmiiller,^^ 
and  others. 

A  positive  blood  culture  is  diagnostic,  a  negative  result  is  not  deter- 
mining. By  a  simple  modification  of  technic,  Fraenkel  and  Kinsey^* 
increased  the  percentage  of  positive  findings  in  pneumonia,  from  20  to 
80  in  the  same  epidemic. 

The  technic  of  culturing  the  blood  is  simple.  The  skin  over  the  vein 
(usually  the  median  basilic)  is  iodinized.  The  sj'ringe  (rendered 
sterile)  to  be  used  should  have  a  capacity  of  10c. cm.  The  vein  is  made 
prominent  by  central  obstruction  (see  infusion,  p.  000),  and  the 
needle  plunged  through  into  the  vein  i*n  a  direction  parallel  to  it  and 
in  the  direction  of  the  blood  stream.  Care  should  be  exercised  not  to 
force  air  into  the  vein.  The  piston  is  caused  to  withdraw  the  blood, 
though  suction  is  not  always  necessary,  as  the  pressure  of  the  blood 
often  pushes  the  piston  upward  and  fills  the  cj^linder.  After  the  blood 
has  been  drawn,  it  should  be  transferred  immediately  to  the  proper 
media.  When  it  is  necessary  to  transport  specimens,  Epstein^^ 
recommends  mixing  the  blood  with  two  per  cent  ammonium  oxalate 
in  test  tubes  to  obviate  clotting.  ' 

Coagulation  of  the  Blood. —  The  time  required  for  the  coagulation  of 
the  blood  is  longer  when  it  is  obtained  from  a  deep  cut  or  from  venous 
puncture  than  when  it  flows  from  a  superficial  wound.  Coagulation 
is  dependent  upon  the  amount  of  blood  allowed  to  flow,  upon  the  pres- 
sure used,  upon  the  temperature,  and  upon  the  nature  of  the  recep- 
tacle used.  The  time  taken  for  coagulation  is  perceptibly  shorter  in 
the  morning  than  in  the  afternoon,  and  it  is  influenced  by  diet  and 
medication.  Uniformity  of  technic  is  important  and,  of  course,  of 
relatively  greater  value.  Slight  deviations  from  standard  are  not  to 
be  seriously  considered.  Extravascular  {in  vitro)  coagulation  is  not 
similar  to  that  which  happens  in  wounds.  The  former  is  dependent 
upon  fibrin  content,  the  latter  upon  a  number  of  factors.  This  is 
shown  by  the  fact  that  in  cachexia,  anemia,  and  typhoid  fever  throm- 
bosis is  frequent,  yet  the  fibrin  content  of  the  blood  is  low,  while,  in 
fibrinous  pneumonitis  and  articular  rheumatism,  where  the  reverse  is 
true,  thrombosis  is  rare. 

The  method  employed  in  laboratory  examinations  is  readily  adjusted 
to  the  time  required  for  coagulation  in  the  wound,  and  then  the  pro- 
cedure becomes  valuable  to  the  surgeon. 


234  INFECTIONS  OF  WOUNDS 

The  coagulation  time  is  prolonged  in  cases  of  jaundice,  anemia, 
anasarca,  hemoglobinemia,  hemophilia,  purpura,  asphyxia,  acute  alco- 
holism, cobra  poisoning,  and  some  toxemias. 

In  jaundice,  the  lengthened  time  of  coagulation  does  not  appear  to 
be  dependent  upon  the  jaundice  per  se,  but  upon  the  coexisting 
toxemia,  hemoglobinemia,  and  anemia.  Fatal  post  operative  hemor- 
rhage is  more  prone  to  occur  in  cases  in  which  the  jaundice  is  due  to 
malignant  disease  obstructing  the  biliary  passages  than  when  the 
jaundice  is  associated  with  cholelithiasis. 

Coagulation  is  hastened  by  the  administration  of  moderate  doses  of 
calcium  salts, —  60-90  grains  daily  for  three  or  four  days.  Large 
doses  given  for  a  longer  period  of  time  retard  coagulation.  If  pos- 
sible, a  coagulation  period  of  five  minutes  should  be  attained  before 
operation  in  cases  of  prolonged  jaundice. 

Cryoscopy. —  The  freezing  point  (expressed  by  the  Greek  delta  A) 
of  normal  blood  ranges  from  between  — 0.56°C.  (30.99°F.)  —  0.58°C. 
f30.95°F.),  while  normal  urine  freezes  between  — 0.9° C.  (30.38°F.) 
and  —  0.2°C.  (31.64:°F.).  Surgically,  cryoscopy  is  used  chiefly  in 
determining  the  integrity  of  the  kidneys. 

In  diseases  of  the  kidney  with  renal  insufficiency,  the  A  of  the  blood 
falls,  while  that  of  the  urine  correspoildingly  rises,  the  blood  becoming 
surcharged  with  excrementitious  substances,  which  the  impaired 
kidney  is  unable  to  eliminate. 

It  has  been  shown  that  the  efficiency  of  the  kidneys,  as  applied  to 
surgery,  may  not  be  standardized  by  cryoscopy  alone;  however,  its 
revelations  should  enjoin  caution,  and  would  suggest  the  employment 
of  additional  measures  of  investigation  in  this  connection. 

BIBLIOGRAPHY 

1.  Jenner's  Method.    Lancet  i,  1889. 

2.  RiBBERT.    Die  Bedentun^-  der  Entziindung.  Bonn,  1905. 

3.  Klein.     Ref .  Centrbl.  f .^  Bakt.  Bd.  i,  xxx,  1901. 

4.  Hiss  and  Zinsser.     Text  Book  of  Bact.  N.Y.,  1916. 

5.  Herter.     Common  Bact.  Inf.  of  the  Digestive  Tract,  N.  Y.,  1907. 

6.  Hektoen.     Jr.  A.  M.  A.,  1903,  xl. 

7.  JociiMANN.     Zeitschr.  f.  klin.  Med.  Iv,  1905. 

8.  Baginsky  and  Sommerfeld.     Arch,  f .  Kinderhellkunde,  1902. 

9.  Badnel.     Rev.  de  Med.,  1899. 

10.  Prochaska.     Centrbl.  f.  inner  Med.,  1900,  xxi. 

11.  Rosenow.     Jr.  Inf.  Dis.,  1904-1906. 

12.  Cole.     Bull.  Johns  Hopkins  Hosp.,  1901,  xii. 

13.  ScHOTTMULLER.    Deutsch.  med.  Woch.,  1900,  Aug.  9th. 

14.  Fraenkel  and  Kinsey.     Jr.  A.  M.  A.,  1904. 

15.  Epstein.     Quoted  by  Hiss  and  Zinsser  No.  4. 


CHAPTER  VIII 
ENTEANCE  POETS   OF   PYOGENIC  INFECTIONS 

Pyogenic  excitants  gain  access  to  the  body  through  wounds  of  the 
skin  and  mucous  membranes;  however,  under  certain  conditions, 
organisms  gain  entrance  through  the  utihroken  skin  or  mucous  mem- 
hranes,  and  migrate  through  the  granulation  tissue  covering  a  wound. 

That  infection  of  the  unbroken  skin  occurs  has  been  demonstrated 
by  Schimmelbusch,^  who  has  shown  that  the  simple  presence  in  the 
skin  of  staphylococci  is  not  sufficient  to  give  rise  to  furuncle,  but  that 
the  cocci  must  be  mechanically  forced  into  hair  follicles  by  friction 
before  infection  will  develop.  After  the  skin  has  been  anointed  with 
the  staphylococcus  culture  the  excitant  may  be  found  along  the  shafts 
of  the  lanugo  hairs,  in  the  ducts  of  the  sebaceous  glands,  and,  to  a 
lesser  extent,  in  the  sudoriferous  glands.  From  foci  of  this  sort  the 
invading  bacteria  enter  the  lymph  channels  and  may,  as  shown  by 
complicating  osteomyelitis,  gain  access  to  the  general  circulation. 

Similar  experiments  were  made  in  connection  with  anthrax  by 
Wasmuth,-  who  showed  that  in  this  manner  the  bacilli  could  be  made 
to  penetrate  the  hair  follicles,  gain  access  to  the  circulation  and  give 
rise  to  fatal  general  infection.  Experimentation  with  the  tubercle 
bacilli  has  led  to  the  same  results. 

The  normal  mucosa  permits  of  the  transmigration  of  bacteria  (fre- 
quently, streptococci,  pneumococci;  less  often,  staphj^lococci,  colon 
bacilli,  etc.),  though  Lexer  ^  and  Bail*  have  shown  that,  in  the  mouth, 
pharynx,  and  gut,  this  occurs  only  when  the  excitants  are  virulent  in 
character.  In  situations  where  the  mucosa  covers  hinphatic  follicles 
(tonsillar  crypts,  tongue  follicles,  racemose  glands  of  the  pharynx  and 
Peycr's  patches),  and  is  loosely  attached,  giving  ready  access  to  the 
leukocytes  (Stohr's  epithelial  spaces),  transmigrated  bacteria  find 
the  conditions  exceedingly  favorable  to  genesis  and  progressive  inva- 
sion (Fig.  116).  Considering  the  phagocj'tic  power  of  the  leukocytes 
it  is  understandable  that  the  invaders  must  be  virulent  in  character 
before  primary  pathogenesis  is  established. 

235 


236 


INFECTIONS  OF  WOUNDS 


Moderately  virulent  bacteria  do  not  ordinarily  provoke  pathogenesis, 
when  located  upon  mucous  membranes,  being  hampered  in  their  activ- 
ities by  the  constant  flow  of  secretions  and  the  movements  of  the  ciliae, 
which  mechanically  tend  to  prevent  invasion.  This  is  indicated  by  the 
fact  that,  normally,  large  numbers  of  pathogenic  organisms  are  found 
upon  the  mucosa  of  the  nose,  mouth,  pharynx,  and  the  respiratory  and 
gastro-intestinal  tracts,  but  is  also  borne  out  by  the  animal  experi- 
ments of  Buchbinder^  who  demonstrated  the  impermeability  of  the 
normal  mucosa  to  bacteria  of  moderate  virulence.  When,  however,  the 
mucosa  is  damaged,  or  its  resistance  lessened  by  paralysis  of  the  ciliary 


.Pi. 


'V    /.v^-.  ■,■■   •  .-^  .  ■  jJj^i^i^,  ■  •■  .••;;,.^-.-."^'i^-- .^■-• 


Fig.  116. —  Tonsillar  Crypt  of  the  Guinea  Pig  Following  Instillation  of  a 
Highly  Virulent  Streptococcus  Culture.  Death  froji  general  strepto- 
coccemia. 

The  cocei  may  be  seen  infiltrating  the  intact  epithelium  at  a  space  of  Stohr, 

movements  of  the  epithelium  of  the  trachea  and  bronchi,  the  result  of 
refrigeration  (Wassermann*')  ;  or  from  circulatory  disturbances,  as 
in  intestinal  strangulation ;  or  from  chronic  inflammation,  especially 
the  naso-pharynx ;  from  chemical  or  mechanical  irritation;  or  from 
superficial  trauma,  the  innocuous  parasite  excitants  become  pathogenic, 
rapidly  multiply,  and  invade  the  tissues. 

The  fact  that  wounds  of  the  nasal,  oral,  and  pharyngeal  mucosa  do 
not  frequently  infect  m^y  be  ascribed  to  the  bactericidal  action  of  the 
secretions  of  this  membrane,  the  presence  of  large  numbers  of  leuko- 
cytes, and  the  vascularity  of  these  regions.     Clairmont^  regards  the 


ENTRANCE  PORTS  OF  PYOGENIC  INFECTIONS     237 

mechanical  removal  of  the  bacteria  b}^  salivary  lavage  to  be  the  most 
important  prophylactic  factor  in  this  connection. 

^Severe  infections  of  mucous  surfaces  with  virulent  excitants  fre- 
quently extend  beyond  the  mucosa,  involve  the  submucosa,  develop 
phlegmonous  inflammation,  and  invade  the  general  circulation.  A 
causative  relationship  between  acute  angina,  articular  rheumatism, 
suppurative  osteomyelitis,  and  metastases  elsewhere  in  the  body  is  thus 
established. 

The  uninjured  granulating  surfaces  of  wounds  are  exceedingly 
resistant  to  the  transmigration  of  even  highly  virulent  bacteria. 
NoetzeP  smeared  granulating  wounds  of  sheep  (which  are  exceed- 
ingly susceptible)  with  virulent  cultures  of  anthrax  and  tetanus,  with 
negative  results.  The  resistance  of  granulation  tissue  to  infection  was 
known  to  the  surgeons  of  earlier  times,  who  always  waited  for  the 
appearance  of  healthy  granulations  before  attempting  plastic  repair 
of  wounds.  Afansieff^  seems  to  have  shown  that  the  secretions  of 
granulating  wounds  not  only  act  as  a  mechanical  lavage,  but  are  also 
distinctly  bactericidal.  However,  the  most  important  protective 
factor  would  seem  to  be  the  laj'ers  of  cellular  elements  in  granulation 
tissue,  which  resist  permeation  much  like  the  epidermis.  Granulations 
are,  however,  much  more  easily  traumatized  than  is  the  skin,  and  when 
once  lacerated  present  a  favorable  atrium  for  the  entrance  of  infection. 
NoetzeP  found  this  to  be  the  case  in  connection  with  experimentation 
with  anthrax  and  tetanus  bacilli. 

Clinical  experience  would  seem  to  accord  with  experimental  obser- 
vation. The  3'ellow  fibrinopurulent  exudate  of  infected  wounds, 
though  infested  with  bacterial  flora,  does  not  seem  to  constitute  a 
menacing  factor,  unless  the  granulating  surfaces  of  the  wound  are 
injured,  either  by  the  forcible  removal  of  adherent  dressings,  by 
ungentle  applications  of,  so-called,  antiseptics,  or  by  the  use  of  the 
curette,  when  absorption  is  likely  to  occur,  and  may  be  followed  by 
lymphangitis,  cellulitis,  and  even  by  general  bacteriemia. 

The  skin  is  most  likely  to  be  the  port  of  entrance  for  staphylo-  and 
streptococci,  the  mucosa  of  the  upper  air  passages  for  strepto-  and 
pneumococci,  the  upper  portion  of  the  g astro-intestinal  canal  for 
strepto-  and  staphylococci,  the  lower  part  of  the  gut  for  the  bacterium 
eoli  (at  times  staphylo-  and  streptococci)  ;  while  the  genito-urinary 
tract  is'  most  frequently  invaded  by  gonococci,  strepto-  and  staphylo- 
cocci, the  bacillus  pyocyaneus,  and,  in  women,  by  the  streptococcus 
alone,  or  together  with  other  pj^ogenic  organisms. 


238  INFECTIONS  OF  WOUNDS 

BIBLIOGRAPHY 

1.  ScHiMMELBUSCH.     Arch.  f.  Ohrenheilkunde,  1889,  Bd   27 

2.  Wasmuth.     Zentrbl.  f.  Bakt.  Bd.  12  1892  '       •     «• 

3.  Lexer.     Arch.  f.  klin.  Cbir.  Bd.  54  1897  "' 

4.  Bail.     Arch.  f.  klin.  Chir.  Bd.  62,  1900,  with  lit. 

5.  BucHBiNDEB.     Deutsch.  Zeitschr.  f .  Chir.  Bd.  55,  1900 
0.  Wassermann.     Deutsch.  med.  Woeh.,  1902 

7.  Clairmont.     Wien  klin.  Wooh.,  1906 

8.  NoTZEL.    Chir.  Kong.  Vehr.,  1897,  ii.* 

9.  Afansieff.    Beitr.  z.  path.  Anat.,  Bd.  22,  1897 


CHAPTER  IX 
PYOGENIC   INFECTIONS   AND    THEIR   TREATMENT 

When  pyogenic  bacteria  gain  access  to  a  wound,  active  invasion  of 
the  contiguous  tissue  follows  after  a  brief  period  of  incubation,  during 
which  time  genesis  of  the  excitants  (establishment  of  virulence)  and 
adaptability  on  the  part  of  the  host  takes  place.  In  this  phenomenon, 
the  bacteria  are  the  aggressors  and  the  bactericidal  action  of  wound 
secretions  constitutes  the  defense. 

When  the  tissues  are  invaded,  these,  too,  marshal  their  protective 
substances,  in  which  they  are  supported  by  the  bactericidal  capacity 
of  the  entire  hody.  The  combat  between  the  invading  aggressors  (the 
bacteria)  and  the  tissues,  with  its  varying  triumphs  and  defeats,  is 
enacted  with  the  presentation  of  the  clinical  picture  of  acute  (at  times 
chronic)  inflammation,  which  as  a  rule  takes  on  the  characteristics  of 
a  suppurative  process. 

When  the  aggressors  are  not  virulent  nor  present  in  large  numbers, 
they  soon  succumb  to  the  defensive  activities  of  the  protective  bacteri- 
cides, and  suppuration  does  not  occur.  Tissue  necrosis  occurs  without 
the  development  of  suppuration,  when  bactericidal  activity-  is  not 
sufficient  to  obviate  the  tissue  destruction  wrought  by  the  bacteria. 
Suppuration  may  be  said  to  take  place  between  these  two  processes, 
i.  e.,  the  aggressors  are  not  destroyed,  nor  do  their  activities  always 
accomplish  progressive  destruction  of  tissue.  When  suppuration  is 
established  the  contest  may  be  regarded  as  wavering ;  for  a  time  the 
aggressors  triumph,  then  the  defensive  action  on  part  of  the  tissues 
enforces  localization  (encapsulation),  and  the  battle  ends  in  the  forma- 
tion of  an  abscess.  Pyogenic  infection  may  be  stated  as  being  char- 
acterized by  the  phenomena  of  acute  purulent  inflammation. 

The  absorption  of  bacteria  and  their  toxins  is  met  at  once  by 
defensive  action  on  part  of  the  host,  though,  this  is  not  often  capable  — 
especially  when  the  attack  is  made  by  virulent  aggressors  —  of  staying 
the  progress  of  the  invaders.  When  inflammator}^  foci  occur,  they 
are  designated  as  lymphogenous  or  hematogenous,  in  accord  with  the 

239 


240  INFECTIONS  OF  WOUNDS 

avenue  of  their  approach  to  their  area  of  localization,  in  contrast  to 
those  entering  from  the  external  world,  called  ectogenous,  and  those 
developing  from  bacteria  already  inhabiting  certain  portions  of  the 
body  (mucous  surfaces  and  skin),  or  those  encapsulated  and  quiescent 
(pyosalpinx),  called  endogeiious  infections. 

The  pathogenesis  of  pus  excitants  is  the  result  of  the  action  of  the 
toxins  originating  in  the  tissues  and  those  liberated  upon  the  dissolu- 
tion of  the  bacterial  bodies  (endotoxins).  The  toxins  of  pyogenic 
bacteria  —  unlike  those  of  tetanus  —  are  poisonous  only  when  present 
in  large  numbers,  or  when  of  virulent  character.  The  toxicity  of 
pyogenic  organisms  is  proportionate  to  the  magnitude  of  the  bacterial 
flora,  and  the  extent  to  which  they  undergo  dissolution.  The  destruc- 
tive action  of  pyogenic  infection  is  considerably  enhanced  by  the 
nutritive  disturbances  consequent  to  circulatory  stasis  (thrombosis). 

The  Underlying  Principles  in  the  treatment  of  pyogenic  inflamma- 
tions are  based  upon  the  response  the  tissues  make  to  the  infection. 
Efforts  at  relief  should  not  be  directed  toward  combating  the  phe- 
nomena attendant  upon  inflammation,  but,  on  the  contrarj",  should  aid 
them  by  complete  immobilization  of  the  affected  part ;  and,  b}'  early 
operative  liberation  of  the  detritus  of  the  contest,  at  the  same  time 
give  opportunity  for  the  expulsion  (by  drainage)  of  the  invading 
bacteria  themselves.  The  earlier  and  the  more  tkorougkly  this  is  done, 
the  sooner  the  tissues  return  to  the  normal,  and  the  less  is  the  penalty 
of  the  contest  —  i.  e.,  loss  of  function.  (The  natural  efforts  at  repair, 
as  expressed  by  the  phenomena  of  inflammation,  were  -ecognized  by 
Landerer^  in  1885.) 

The  fundamental  principles  in  the  treatment  of  pyogenic  infections 
constitute  the  basis  of  Bier's^  hyperemia.  While,  in  the  treatment  of 
infectious  inflammations,  main  reliance  is  to  be  placed  upon  early  free 
incision  and  drainage.  Bier  increases  the  quantity  of  hlood  in  the 
infected  area,  thus  amplifying  its  bactericidal  capacity.  However,  it 
is  nevertheless  advisable  to  precede  the  employment  of  Bier's  hyper- 
emia by  first  providing,  as  far  as  possible,  for  the  rapid  egress  of 
the  cause  of  the  inflammatory  process  (Lexer^),  a  procedure  which  in 
no  way  interferes  with  the  subsequent  employment  of  the  Bier  method 
of  treatment. 

In  the  early  stages  of  inflammation,  the  immohilizing  dressing  is  of 
great  importance  and,  in  some  instances,  is  sufficient  to  permit  of 
restitution  to  the  normal.  Suspension  and  elevation  of  the  infected 
part  enhances  venous  return,  lessens  the  pressure  in  the  lymphatics, 


PYOGENIC  INFECTIONS  AND  THEIR  TREATMENT      241 

and  tends  to  obviate  necrosis  from  circulatory  stasis.  These  measures, 
carefully  applied,  give  considerable  relief  from  pain.  The  dressings 
coming-  in  contact  with  the  skin  may  be  advantageously  coated  with 
sterile  ointments  (5-10  per  cent  zinc  or  boric  vaselin),  which  are 
agreeably  refrigerant,  need  not  be  changed  for  several  days,  and  may 
be  renewed  with  but  little  pain  to  the  patient. 

The  application  of  cold  (ice  bag)  to  inflamed  areas  relieves  pain.  In 
superficial  inflammations  it  lessens  hyperemia  by  causing  contraction 
of  the  blood  vessels,  and,  when  applied  for  several  days,  may  cause 
tissue  necrosis.  For  this  reason  the  use  of  the  ice  bag  is  only  per- 
missible in  deeply  located  inflammatory  processes  such  as  peritoneal 
infection,  in  which  the  slowing  of  the  process  is  destined  to  encourage 
localization. 

Wet  dressings  also  lessen  pain  when  applied  warm.  The  warm 
moisture  may  be  maintained  for  a  considerable  period  of  time  by 
incasing  the  dressing  with  perforated  rubber  tissue.  Infections  of 
moderate  degree  may  be  arrested  in  this  way;  however,  when  there 
is  much  tension  the  increased  hyperemia  due  to  warm  moisture 
enhances  exudation  and  causes  ohjectionahle  pressure  upon  the  tissues; 
in  addition  to  this,  the  attendant  maceration  of  soft  parts  promotes 
extension  of  bacterial  invasion,  fermentative  digestion,  and  necrosis 
of  tissue.  Lexer*  reports  a  case  of  sloughing  of  the  entire  mammary 
gland  following  persistent  application  of  warm  poultices.  Warm 
moisture  may  be  used  for  the  purpose  of  aiding  the  proliferation  of 
deep  abscesses  toward  the  surface ;  however,  on  general  principles,  its 
use  is  rarely  advisable. 

When  pus  is  detected  by  fluctuation,  or  its  presence  is  indicated  by 
various  clinical  manifestations,  or  its  formation  is  suspected,  the 
inflamed  area  should  at  once  be  freely  incised  with  the  knife.  The 
incision  is  destined  to  give  egress  to  the  pus  and  to  lessen  tension. 
The  knife  should  divide  the  tissues  "under  the  eye"  and  penetrate  to 
the  desired  depth  without  injury  to  important  anatomical  structures. 
Puncture  of  the  pus  area  or  drainage  through  stab  wounds  is  to  be 
avoided,  except  for  the  purpose  of  evacuating  circumscribed  lymphatic 
abscesses. 

Preliminary  disinfection  of  the  skin  is  best  attained  by  the  applica- 
tion of  tincture  of  iodin  (p.  87). 

It  is  imperative  that  incision  of  large  phlegmonous  areas,  of  deeply 
located  abscesses,  and  of  purulent  joint  cavities  be  executed  under 
narcosis  and  after  exsanguination  of  the  part  (except  in  the  presence 


242  INFECTIONS  OF  WOUNDS  .-; 

of  acute  lymphangitis).  Preliminary  exsanguination  (v,  Esmarch, 
p.  32)  makes  easy  the  detection  of  hidden  spaces  and  renders  unlikely 
injury  to  important  nerves,  vessels,  etc. 

^  Incision  of  finger  tips  may  be  accomplished  painlessly  by  the 
employment  of  OberstV  perineural  infiltration  method,  in  which  the 
finger  is  constricted  at  its  base  and  the  anesthetic  injected  into  healthy 
tissue.  The  infiltration  of  inflamed  areas  (Schleich's®  method)  is 
likely  to  propel  infectious  material  into  the  surrounding  tissues,  and 
should  be  avoided.  The  surfaces  of  small  abscesses,  furuncles,  and 
small  carbuncles  may  be  sprayed  with  ethyl  chlorid  before  opening. 

3Iechanical  and  chemical  irritation  of  the  tissues  cannot  be  too 
strongly  condemned.  Squeezing,  wiping,  and  irrigation  of  the  wound ; 
the  scooping  out  of  necrotic  tissue,  tearing  with  the  fingers  and  re- 
tractors, boring  with  sounds  and  dressing  forceps ;  indeed,  all  ungentle 
manipulations  tend  to  traumatize  the  part  and  not  infrequently  pro- 
voke massive  absorption  of  bacteria  and  their  toxins  which  thus  gain 
access  to  the  lymph  and  blood  currents.  In  some  instances,  rough 
handling  causes  the  liberation  of  thrombi,  and  thus  measures  of 
relief  are  followed  —  not  by  a  fall  of  temperature  and  arrest  of  the 
infiammatory  process,  but,  by  a  secondary  chill,  fever,  and  the  de- 
yelopment  of  lymphangitis,  cellulitis,  pulmonary  embolism,  metastatic 
foci  and  bacteriemia. 

Cheinical  irritation  of  the  wound  leads  to  tissue  necrosis  if  the 
agent  used  is  antiseptically  efficient  (v.  Bruns'^  standardizes  the  re- 
quired bactericidal  efficiency  of  a  chemical  antiseptic  as  equivalent 
to  the  action  of  pure  carbolic  acid  applied  for  one  minute) .  The  necro- 
tic tissue  scab  thus  formed  confines  the  bacteria  and  toxin-laden  exu- 
dj^te  and  favors  their  entrance  into  contiguous  tissues.  The  usual 
ap,iiseptic  solutions,  when  applied  for  a  short  period  of  time,  do  not 
seriously  damage  the  tissues,  and  may  be  said  to  destroy  superficially 
located  bacteria;  when  in  prolonged  contact  with  the  tissues  the}'" 
unquestionably  lessen  its  nutrition  and  favor  necrosis.  Pastes  and 
powders  (glutol,  glutol  serum,  iodoform,  bismuth,  etc.)  also  interfere 
with  the  discharge  of  wound  secretions  and  quite  properly  may  be 
discarded. 

The  freshly  made  liherating  incision,  together  with  the  more  or  less 
irregular  cavitations  of  the  infected  area,  should  be  loosely  tamponed 
with  dry  iodoform  gauze.  This  tamponade  is  at  first  hemostatic  and 
by  its  capillary  action  mechanically  favors  the  discharge  of  blood, 
blood  serum,  and  infectious  substances,  which  together  with  the  con- 


PYOGENIC  INFECTIONS- AND  THEIR  TREATMENT      243 

stantly  exuded  wound  secretions  are  taken  up  by  the  protective  dress- 
ing. Gauze  saturated  with  antiseptic  solutions  does  not  possess  these 
characteristics;  it  is  not  efficiently  bactericidal,  nor  does  capillarity 
begin  until  its  moisture  has  evaporated  to  an  extent  represented  by 
iodoform  gauze.  Moist  antiseptic  gauze  covered  with  rubber  tissue 
possesses  no  capillary  action.  Observations  made  in  this  connection 
show  that  sterile  wet  gauze  brought  in  contact  with  infected  wounds 
is  soon  infested  with  bacteria  that  find  their  way  from  the  inflam- 
matory area  and  rapidly  multiply  in  the  new  environment.  In  the 
treatment  of  deeply'  located  purulent  infections,  tamponade  should  be 
supplemented  by  tube  or  other  drainage. 

The  tampon  should  not  be  removed  for  twenty-four  hours,  to  avoid 
inflicting  fresh  trauma  upon  the  wound  surfaces;  it  should  also  not 
be  permitted  to  remain  in  sitio  for  longer  than  forty-eight  hours, 
as  by  that  time  its  capacity  as  a  drain  is  exhausted  and  it  is  so 
heavily  saturated  with  exudate  that  it  becomes  mechanically  obstruc- 
tive to  drainage.  The  tampon  should  be  removed  without  damage  to 
the  edges  of  the  wound  (where  it  is  usually  adherent).  This  may  be 
accomplished  by  carefully  trickling  3  per  cent  hydrogen  peroxid  upon 
the  dressing  and  allowing  the  rapidly  forming  ''  bubbles  "  to  lift  the 
gauze  gently  from  its  bed.  In  this  way  the  desired  end  is  gained 
without  causing  fresh  bleeding. 

At  each  change  of  dressing  the  wound  is  to  be  treated  with  painstak- 
ing gentleness.  Thick  pus  may  be  evacuated  by  posture  or  by  slowly 
flowing  sterile  fluid,  and,  if  necessary,  gentle  wiping  with  soft  gauze 
may  be  resorted  to.  The  transient  retention  of  exudate  is  less  harm- 
ful than  ungentle  efforts  at  removal.  If  the  patient  be  susceptible 
to  iodoform  dermatitis,  dry  sterile  gauze,  or  gauze  impregnated  with 
determatol,  xerol,  Crede's  silver  salts,  etc.,  may  be  employed.  Tam- 
ponade and  drainage  is  maintained,  and  the  wound  kept  open  as  long 
as  pus  is  formed.  In  a  few  days  proliferation  of  granulation  tissue 
begins  and  the  exuded  pus  becomes  thick,  creamy  and  more  or  less 
tenacious,  which  renders  the  capillary  action  of  the  tampon  insuffi- 
cient for  the  purpose  of  its  discharge,  especially  when  deep  cavitation 
is  present.  At  this  time  rubber  tubes  of  liberal  size  may  be  used  and 
the  dry  tamponade  replaced  by  moist  gauze  compresses  (without  the- 
application  of  rubber  tissue),  or  gauze  covered  with  suitable  oint- 
ments may  be  applied.  The  moist  compresses  obviate  gumming  of  the 
wound,  cause  moderate  irritation  —  giving  rise  to  slight  hyperemia  — 
promote  the  flow  of  exudate  and  cleanse  the  granulating  surfaces.    At 


244 


INFECTIONS  OF  WOUNDS 


this  stage  of  the  process,  mechanical  removal  of  pus  or  fibrinous  exu- 
date from  the  granulations  is  likely  to  result  in  reinfection,  the  out- 
come of  trauma  to  the  delicate,  newly  formed  repair  tissue. 

Ointments  consisting  of  hydrargyri  cinereum,  hydrarg,  oxid.  rubr. 
4-8  per  cent  with  vaselin,  or  10  per  cent  zinc  or  boric  acid  may  be 
advantageously  used. 


Fig.  117, —  Glass  Coxnection  Tubes,  Vision  Tubes  and  Stop  Cocks  (Leriehe). 


For  moistening  dressings,  3  per  cent  liq.  alum  acet.,  or  2  per  cent 
boric  acid  may  be  emploj^ed.  If  evaporation  of  the  moisture  is  not 
prevented  by  confining  the  dressing  with  rubber  tissue,  the  gradu- 
ally drying  gauze  exercises  a  desirable  degree  of  capillarity. 

Muscular  contractions  injure  the  aifected  tissues,  improperly  ap- 
plied dressings  cause  circulatory  disturbances  and  prevent  the  free 


PYOGENIC  INFECTIONS  AND  THEIR  TREATMENT     245 


S 


*  g  a  g  . 


discharge  of  exudates ;  therefore,  the  patient  should  be  kept  in  bed,  and 
the  affected  part  immobilized  in  splints  and  suspended  with  appro- 
priate apparatus  until  the  tense  red  skin  of  the  infected  area  pales  and 
shrinks,  and  healthy  granulation  is  firmly  established. 

The  Carrel-Dakin  Treatment. — Recently  an  effort  at  the  chemical 

sterilization  of  in- 
fected wounds,  espe- 
cially those  in  which 
complete  mechanical 
removal  of  devital- 
ized and  infected 
tissue  is  not  feasible, 
has  been  made  by 
means  of  the  Carrel- 
Dakin®  method. 

In  this  connection 
Leriche^  says  in  sub- 
stance: The  novelty 
of  the  Carrel  meth- 
od of  wound  treat- 
ment consists  in  its 
providing  a  pro- 
tracted and  intimate 
contact  between  a 
relatively  non-irri- 
tant antiseptic 
agent  and  the  in- 
fected wound  sur- 
face. In  pursuance 
of  this  object  the 
the  same  degree  of 
concentration  of  the 
antiseptic  solution 
Fig.  118. —  Carrel's  Distributing  Tubes   (Leriche).      must   be    constantly 

maintained,  and  this  necessitates  a  special  technic  for  the  constant  re- 
newal of  Dakin's  fluid  which  is  very  unstable  and  easily  decomposed. 
A  preliminary  requirement  is  the  earliest  possible  surgical  revision 
of  the  wound.  This  is  followed  by  the  institution  of  the  Carrel  pro- 
cedure which  has  for  its  main  object  the  sterilization  of  the  wound  by 
chemical  means  and  aims  at  accomplishing  this  purpose  through  a 


246  INFECTIONS  OF  WOUNDS 

special  mode  of  application  of  a  definite  antiseptic  solution,  i.  e., 
Dakin's  fluid,  claimed  to  be  isotonic  with  blood  serum.  The  early  union 
of  the  wound  margins  by  sutures  or  other  means,  which  this  method 
renders  practicable,  argues  for  the  efficiency  of  the  method  in  the 
treatment  of  infected  war  wounds. 

The  method  takes  its  name  from  the  technic  specially  devised  by 
Carrel  for  bringing  Dakin's  fluid  of  sodium  hypochlorite  into  contact 
with  the  interior  of  infected  wounds.  Dakin's  solution  in  a  septic 
wound  acts  both  as  an  antiseptic  and  as  a  cleansing  agent  or  remover 
of  dead  tissue  liable  to  serve  as  a  nidus  for  microorganisms.    The  solu- 


FiG.  119. —  Mode  in  Which  the  Small  Distributing  Tubes  Are  Carried 
Through  the  Dressings  to  the  Various  Parts  of  the  Wound  (Carrel  and 
Dehelly). 


tion  possesses  hemolytic  properties  and  will  dissolve  recent  blood  clots ; 
so  that  an  efficient  hemostasis  is  essential  to  guard  against  the  dangers 
of  secondary  hemorrhage. 

Dakin's  fluid  is  used  in  a  solution  of  0.5  per  cent  and  is  best  pre- 
pared according  to  the  formula  of  Daufresne;  this  is  a  complicated 
procedure  and  is  related  in  detail  by  Leriche.® 

The  equipment  required  for  the  purpose  is:  (1)  A  sodium  hypo- 
chlorite solution  of  0.5  per  cent  strength,  prepared  according  to  the 
formula  of  Daufresne.  (2)  A  glass  resceptacle  holding  from  500  to 
1,000  c. cm.  (3)  Ordinary  medium  sized  rubber  tubing,  two  yards.  (4) 
A  movable  clamp  for  the  regulation  of  the  flow  through  the  main 


PYOGENIC  INFECTIONS  AND  THEIR  TREATMENT      247 


distributing  tube.  (5)  Rubber  instillation  tubes  of  assorted  widths 
(average  size  No.  16  French)  and  about  25  em.  in  length.  The  ends 
are  tied,  and  a  number  of  very  small  holes  are  then  punched  out  of 
the  tubes ;  these  holes  are  no  larger  than  1mm.  or  1/25  of  an  inch  in 
diameter.  The  internal  diameter  of  the  primary  and  secondary 
tubes  is  7  mm.  and  that  of  the  final  distributing  tubes  is  4  mm.  (6) 
Ordinary  rubber  drainage  tubes,  without  perforations,  25  to  35  cm. 
in  length.      (7)    Glass  tubes  for  connection  and  distribution.      (8) 

Cotton  surrounded  '  by 
gauze,  for  dressings  of  dif- 
ferent sizes,  (a)  fitting 
well  around  the  leg;  (b) 
fitting  well  around  the 
arm;  (c)  a  small  size.  The 
thickness  of  these  dressings 
is  about  3  cm. ;  they  consist 
of  a  layer  of  absorbent  cot- 
ton and  a  thicker  layer  of 
non-absorbent  cotton.  The 
dressing  is  held  by  straps 
of  webbing,  with  adjusta- 
ble buckles.  (9)  Steril- 
ized gauze  squares  soaked 
in  yellow  vaselin  (petro- 
latum) serve  for  the  pro- 
tection of  the  skin.  White 
vaselin  must  not  be  used. 

Preliminary  care  of  the 
wound     {debridement)     is^ 

Note  on  the  main  distributing  tube  the  pinch  followed  by  introduction  of 

cock  below  the  reservoir.     The  wound  is  covered  ,i      .      ,.•,,  "  .  ,  „. 

with  the   dressinfi:,  which  is  fastened  by   safety  tne  mstlilation  tubes.      ihe 

pins.  The  distributing  tube  is  similarly  held  in  nature  of  the  WOUnd  o'OV- 
place    bv    being    pinned    to     the    plaster    cast  ,,  ,      .  n^  -, 

(Leriche).  erns    the    placmg    of    the 

tubes,  which  must  be  so  as 
to  bring  the  fluid  in  direct  contact  with  every  portion  of  the  wound. 
The  technic  varies  according  to  the  character  of  the  lesion. 

Surface  Wounds. —  These  wounds  are  covered  with  a  thin  layer 
of  gauze,  on  which  lie  the  instillation  tubes,  in  a  number  adapted  to 
the  needs  of  a  given  case.  Rubber  cuffs  and  sutures  retain  the  tubes 
at  the  wound  margins.     A  two  way  flux  tube  is  sometimes  used.     The 


Fig.   120. —  Showing   Carrel  Method  of  Irri- 
gating Wound  with  the  Dakin  Fluid. 


248  INFECTIONS  OF  WOUNDS 

placing  of  the  tubes  directly  on  the  surface,  without  the  intervening 
layer  of  gauze,  would  result  in  clogging  and  blocking  of  the  orifices 
by  granulation.  Access  of  the  germicidal  solution  to  all  parts  of  the 
wound  would  be  hindered  by  thick  gauze  layers  stiffened  with  the 
secretion  of  the  wound. 

Penetrating  TVounds. —  A  rubber  tube  without  openings  in  its 
walls  is  passed  down  nearly  to  but  without  reaching  the  floor  of  a 
simple  wound  cavity,  with  the  result  that  the  disinfecting  liquid  wells 
up  from  the  bottom.  The  ragged  walls  of  wound  cavities  at  the  end 
of  wide  channels  must  be  held  up  by  means  of  a  little  gauze,  so  as 
to  facilitate  the  universal  spreading  of  the  bactericide.  Perforated 
tubes  wrapped  in  toweling  (Fig.  118)  are  used  for  penetrating  wounds 
with  a  low  dependent  point  of  entrance  (posterior  surface  of  arms  and 
legs,  back,  and  buttocks),  but  non-perforated  tubes  may  be  employed, 
the  essential  point  being  the  continued  contact  of  the  disinfecting 
agent  with  the  wound. 

Perforating  "Wounds. —  Infection  of  such  wounds  is  controlled  by 
passing  a  perforated  tube,  tied  at  its  end,  from  the  lower  to  the 
higher  wound.  The  disinfecting  liquid  is  distributed  over  the  entire 
wound  as  it  flows  from  the  small  openings  in  the  tube  and  returns  to 
the  lower  orifice  along  the  wound  channel. 

A  hypochlorite  bath  of  ten  to  fifteen  minutes  is  the  treatment  for 
open  amputation  stumps  and  for  peripheral  wounds  of  the  extremities, 
to  be  repeated  every  two  hours  until  the  wound  is  sterilized.  Cutan- 
eous irritation  with  the  soda  hypochlorite  is  guarded  against  by  smear- 
ing the  skin  with  sterile  yellow  vaselin. 

In  order  to  determine  when  secondary  apposition,  by  suture  or 
otherwise,  of  the  wound  is  permissible,  the  secretions  from  the  wound 
surfaces  are  subjected  to  bacterial  examination  at  frequent  intervals; 
for  the  purpose,  ' '  smear  specimens  ' '  obtained  with  the  platinum  loop 
are  subjected  to  microscopical  examination.  This  is  regarded  as  more 
desirable  than  the  employment  of  cultures.  Not  less  than  three  suc- 
cessive sterile  results  should  be  relied  upon  in  this  connection.  The 
wound  is  closed  in  accord  with  general  surgical  principles. 

In  all  acute  purulent  and  putrefactive  infections,  prophylaxis  is  an- 
important  factor.  Cases  of  erysipelas,  phlegmon,  purulent  osteomye- 
litis, bacteremia  with  metastases,  etc.,  should  be  placed  in  a  department 
by  themselves.  The  personnel  of  this  department  should  not  be  em- 
ployed in  the  general  operating  room.  The  surgeon  in  charge  of 
infected  cases  should  wear  rubber  gloves  and  manipulate  dressings 


PYOGENIC  INFECTIONS  AND  THEIR  TREATMENT      249 


with  forceps;  in  short,  every  precaution  to  obviate  the  transference  of 
infection  should  be  carefully  exercised. 

Treatment  With  Passive  Hyperemia. —  Passive  hyperemia  (Bier-) 
is  produced  by  constricting'  the  central  portion  of  the  infected  limb 
with  a  thin  elastic  rubber  bandage  (6  cm.  in  breadth)  with  sufficient 
tension  markedly  to  obstruct  return  circulation.  For  the  purpose  of 
equalizing  pressure,  the  application  of  the  rubber  bandage  is  pre- 
ceded by  encircling  the  area  of  constriction  with  several  layers  of 
mull.     The  last  turn  of  rubber  bandage  is  fastened  with  a  safety  pin 

'or  may  be  made  to  "  paste  itself  " 
in  place  with  water  (Fig.  121).  At 
intervals  of  several  hours  the  site  of 
constriction  is  altered,  the  bandage 
being  applied  either  lower  or  higher 
on  the  limb.  xVbove  the  shoulder 
and  hip,  and  on  the  scrotum  a  tubu- 
lar —  and  on  the  neck  a  band  shaped 
constrictor  (3  cm.  in  breadth)  is 
used. 

The  character  of  the  arterial  pulse 
should  not  he  affected  by  the  con- 
striction, which  is  intended  to  slow 
the  circulation,  not  abolish  it.  Dur- 
ing constriction  the  limb  becomes 
warm  and  edematous  and  pain  grad- 
ually disappears.  If  pain  increases, 
the  pressure  is  too  great.  To  ob- 
viate this,  constant  surveillance  is 
necessary  and  the  degree  of  constric- 
tion must  be  frequently  modified.  If  stasis  is  maintained  for  too  long 
a  period  of  time,  the  resultant  edema  and  disturbances  in  tissue  nu- 
trition become  a  grave  menace,  one  which  cannot  be  too  strongly 
emphasized.  Constriction  is  maintained  daily  for  ten  hours,  and 
in  severe  infections  for  twenty-two  hours.  After  removal  of  the 
bandage,  elevation  of  the  part  lessens  edema. 

Small  incisions  are  made  in  areas  showing  a  tendency  to  break 
down,  and  larger  ones  ma}'  be  employed  for  the  release  of  pus.  Tam- 
ponade is  regarded  as  unnecessar}",  and  only  deep  areas  are  drained. 
Pus  is  evacuated  when  the  dressing  is  changed  (daily).  Passive  mo- 
tion of  the  affected  part  is  instituted  at  once  and  active  movements 


Fig.  121. —  CoxsTRicTioN  Applied  to 
Arm  (Bier). 


250  INFECTIONS  OF  WOUNDS 

encouraged,  with  the  view  of  obviating  adherence  of  tendons  and 
joints.  For  the  same  reason  the  parts  are  not  immobilized  and  the 
dressings  restricted  to  lightly  applied  sterile  fabric. 

Passive  hyperemia  is  recommended  for  all  acute  inflammatory  pro- 
cesses of  the  extremities,  head,  and  scrotum,  i.  e.,  hnnphangitis,  phleg- 
monous inflammations,  panaritium,  osteomyelitis,  purulent  sjTiovitis, 
gonorrheal  arthritis,  infected  accidental  and  operative  wounds,  and  to 
facilitate  the  separation  of  gangrenous  parts. 

The  rationale  of  the  method  of  treatment  is  based  on  the  theory 
that  it  increases  these  natural  defensive  processes  of  the  tissues 
and  of  the  body,  concerned  in  overcoming  the  infection ;  that  it  obviates 
the  necessity  for  large  incisions,  and  the  application  of  immobilizing 
apparatus;  and  also,  that  early  passive  and  active  motion  tends  to 
lessen  loss  of  function. 

The  employment  of  a  method  of  treatment  based  on  the  assumption 
that  the  bod}^  is  quite  capable  of  taking  care  of  an  infection  is  per- 
haps justified  if  the  invading  process  is  a  mild  one,  but  is  fraught  with 
great  danger  if  the  reverse  obtains  and  the  character  of  the  process 
happens  to  be  a  virulent  one.  If  this  basic  assumption  is  to  be  relied 
upon,  then  the  outcome  in  each  instance  would  be  entirely  dependent 
upon  the  severity  of  the  infection  and  the  degree  of  resistance  of  the. 
host,  neither  of  which  may,  with  any  degree  of  certainty,  be  fore- 
seen. 

The  most  desirable  action  ascribed  to  "  constriction  congestion  "■ 
is  its  capacity  mechanically  to  rid  the  edematous  tissues  of  infec- 
tious substances.  The  assumption  that  transudates  increase  the  quan- 
tity of  protective  substances  has  proved  to  be  a  fallacious  one.  This 
is  shown  by  the  fact  that  fresh  wounds  are  rapidly  cleansed  when  the 
f.ow  of  secretions  is  increased  hy  the  use  of  central  constriction,  and 
also  may  be  obser^-ed  when  an  inflammatory  focus  is  widely  opened! 
before  necrosis  or  suppuration  has  occurred. 

Constriction  hyperemia  may,  and  often  does,  act  favorably  and; 
permits  the  omission  of  tamponade  after  ample  provision  for  the  ex- 
ternal discharge  of  infectious  suhstances  is  made,  —  but  it  cannot  be? 
regarded  as  helpful  when  its  use  increases  the  burden  of  the  tissues 
concerned  in  taking  care  of  the  exudate.  On  the  contrary,  the  increase 
in  transudate,  in  closed  infected  foci,  is  distinctly  harmful,  as  it 
raises  the  pressure  in  the  inflammatory  area  and  favors  the  propulsion 
of  toxins  and  bacteria  into  the  contiguous  healthy  tissues.  Therefore, 
infectious  infiltrates  should  be  freely  incised  and  drained  —  not  merely 


PYOGENIC  INFECTIONS  AND  THEIR  TREATMENT      251 

punctured  —  before  tissue  necrosis  occurs,  or  central  constriction  is 
applied.  Bleeding  must  also  be  arrested  by  means  of  tamponade  be- 
fore the  application  of  the  constrictor.  The  subsequent  removal  of 
the  tampon  is  facilitated  by  the  increased  wound  secretion  induced  by 
the  central  obstruction. 

Forcible  evacuation,  of  pus  by  pressure,  early  passive  and  active 
motion,  and  the  omission  of  the  immobilizing  dressing  are  not  advis- 
able. The  use  of  massage  during  acute  inflammation  should  not  be 
permitted  — •  indeed,  all  efforts  at  relief  involving  the  development  of 
dangerous  consequences  should  he  avoided,  especially  when  the  indi- 
cations presented  are  so  manifestly  met  by  measures  that  are  devoid 
of  menace  and  of  greater  therapeutic  value. 

Wrede^*'  working  with  a  vast  amount  of  clinical  material  furnished 
by  Lexer,  summarizes  his  analj^sis  of  constriction  hyperemia  as  fol- 
lows: 

In  all  mild  stationary  processes  attended  with  moderate  or  declin- 
ing temperature,  good  results  may  be  attained  if  constriction  treat- 
ment is  begun  on  the  first  or  second  day.  Mild  inflammations  recede 
under  constriction  hyperemia,  or  form  small  localized  abscesses  which 
rapidly  heal  after  incision  much  in  the  seme  way  as  obtains  with  immo- 
bilization or  the  use  of  moist  compresses.  Often,  however,  the  infil- 
tration extends  (even  in  light  infections  and  after  early  constriction) 
more  rapidly  than  after  the  ''poultice  treatment,"  a  circumscribed 
inflammation  develops  into  acute  spreading  phlegmon  and  suppur- 
ating cavities  suddenly  invade  the  contiguous  healthy  tissues.  The 
early  use  of  constriction,  following  free  incision  of  infected  tendon 
sheaths,  succeeds  in  preserving  their  motility  and  would  seem  to 
preserve  the  usefulness  of  purulent  joints.  This  is  also  accomplished 
by  the  usual  methods  of  treatment  (p.  239).  The  time  required  for 
recovery  is  not  shorter  than  obtains  with  early  incision  and  dry  tam- 
ponade, if  this  is  standardized  from  the  viewpoint  of  ultimate  outcome 
and  not  measured  by  the  healing  of  the  wound.  In  severe  virulent  in- 
fections the  early  use  of  cmistriction  has  done  harm,  the  local  and 
constitutional  disturbances  being  greater  than  obtain  in  this  class 
of  cases  when  early  incision  and  tamponade  is  used.  Among  other 
unfortunate  accidents  attendant  upon  the  employment  of  constriction 
hyperemia,  Wrede  has  observed  extension  of  infection  as  evidenced 
by  infiltration,  abscess  formation,  thrombophlebitis,  lymphangitis, 
proliferation  of  pus  into  contiguous  parts,  general  infection ;  and,  in 
a  moderate  case  of  streptococcus  arthritis  of  one  week's  standing,  the 


252  INFECTIONS  OF  WOUNDS 

treatment  was  followed  by  purulent  metastasis;  also,  a  fatal  intoxi- 
cation occurred  in  a  child  afflicted  with  a  pneumococcus  infection  of 
the  knee  joint. 

Treatment  With  Suction. —  Hyperemia  of  restricted  areas  may  be 
produced  by  the  use  of  the  suction  apparatus  devised  by  Klapp."  The 
apparatus  consists  of  a  hollow  glass  bulb  from  which  the  air  is  ex- 
hausted by  means  of  a  suction  syringe  or  thin,  hollow  rubber  ball. 
The  chief  benefit  derived  from  the  method  is  ascribed  to  its  capacity 
to  remove  infectious  substances  from  the  site  of  the  infection. 

The  glass  cup,  which  is  constructed  to  fit  various  portions  of  the 
body,  is  used  daily  for  about  forty-five  minutes,  during  which  time  it 
is  removed  every  five  minutes  for  from  one  to  three  minutes.    The  edge 


Fig.  122. —  Suction  Apparatus  for  Mastitis  (after  Klapp). 

of  the  glass  is  coated  with  vaselin  to  prevent  the  entrance  of  air,  and 
the  cup  must,  of  course,  be  sterilized  by  boiling  before  being  applied. 
Prolonged  use  of  the  apparatus  causes  circulatory  stasis  and  hemor- 
rhagic infiltration  of  the  tissues.  A  method  of  application  is  shown 
in  Fig.  122. 

The  measure  is  useful  for  the  removal  of  exudates  and  necrotic 
tissue  in  cases  of  furuncle,  carbuncle  wuth  necrosed  areas,  small  open 
inflammatory  foci  on  the  fingers,  in  the  breast,  in  the  lymphnodes,  in 
fact,  in  all  localized  processes  which  are  not  progressing,  removing, 
as  it  does,  with  a  minimum  of  trauma,  the  end  products  of  infection, 
and,  in  a  certain  number  of  instances,  obviating  the  necessity  for  wide 
incision.  In  cases  of  this  sort  suction  may.be  used,  but  is  to  he  avoided 
in  instances  where  there  is  hard,  hrawny  infiltration  without  areas  of 


PYOGENIC  INFECTIONS  AND  THEIR  TREATMENT      253 

softening,  or  severe  rapidly  extending  inflammation,  especially  when 
thrombophlebitis  is  present.  In  the  latter  class  of  cases,  the  use  of 
the  suction  treatment  causes  delay  in  the  execution  of  free  incision 
and  tamponade  and  permits  of  dangerous  extension  of  the  process,  a 
conception  borne  out,  not  alone  by  clinical  experience  (Lexer,^^ 
Wrede,^^  Zangemeister,^*  etc.),  but  also  by  animal  experimentation 
(Frangenheim^^).  Suction,  in  the  presence  of  thrombophlebitis,  is 
likely  to  loosen  the  fibrinous  deposits,  causing  embolism,  and,  when 
applied  to  unopened  inflammatory  tissue,  causes  thickening  of  the 
exudate,  rendering  its  subsequent  removal  difficult. 

Hot  Air  Treatment. —  Iselin^*'  used  hot  air  for  the  production  of 
hyperemia  in  cases  of  purulent  infections  of  the  tendon  sheaths  of 
the  hand  with  good  effect.  The  measure  is  emploj'ed  after  the  part  is 
incised  and  drained.     Its  use,  before  this  is  done,  favors  necrosis. 

The  day  after  incision  and  drainage,  the  part  is  placed  in  the  hot 
air  apparatus  once  or  twice  daily  for  two  hours.  During  the  treat- 
ment the  dressings  are  removed  and  the  part  wrapped  in  dry  sterile 
fabric  capable  of  absorbing  the  moisture  consequent  to  the  heat. 

Speed}'  decline  of  suppuration,  and  prevention  of  tendon  necrosis 
and  enhanced  healing,  are  claimed  to  result  from  this  method  of 
treatment.  Theoretically,  this  should  be  the  case,  as  the  preliminary 
incision  of  the  part  permits  the  hyperemia  to  furnish  additional  tran- 
sudate, thus  increasing  wound  secretion,  which  favors  the  expulsion  of 
infectious  substances  and  has  a  tendency  to  lessen  nutritive  disturb- 
ances and  aids  repair. 

Antiferment  Treatment. —  The  digestion  and  dissolution  of  tissues 
damaged  by  pyogenic  infection  is  the  result  of  the  action  of  proteolytic 
leukocytic  ferments.  AVith  this  in  mind,  E.  Miiller^^  conceived  the 
idea  that  ferments  might  readily  be  produced  in  excessive  quantity, 
and  to  meet  this  condition  the  use  of  antiferments  would  lessen  diges- 
tion of  tissue  and  restrict  the  formation  of  purulent  exudate. 

Blood  serum  (200  c.cm.),  obtained  by  phlebotomy  or  during  opera- 
tion, sterile  serous  or  serofibrinous  transudates  drawn  from  cavities 
(rich  in  albumin),  ascitic  fluid,  or  the  normal  serum  of  animals  treated 
with  pancreotrypsin,  may  be  used  for  the  purpose.  Inflammatory  pro- 
cesses are  widely  sectioned  and  packed  with  gauze  saturated  with 
the  serum.  Fistulas  are  injected  with  it.  Abscess  cavities,  after  evacu- 
ation of  the  pus,  are  filled  with  it.  Kolaczek,^*  Peiser,^"  and  Joch- 
mann  and  Batzner^"  report  good  results  following  its  use  in  sharply 
circumscribed  abscesses  (breast  and  IjTuph  nodes),  fistulse  of  soft  parts 


254  INFECTIONS  OF  WOUNDS 

and  infected  wounds.     It  is,  however,  not  satisfactorily  operative  in 
arresting  tlie  progress  of  acute  extending  pyogenic  infections. 

Tliis  is  quite  understandable.  Miillers  treatment  is  directed 
toward  neutralizing  the  effect  of  the  excess  of  proteolytic  ferment; 
a  futile  effort,  since  the  leukocytic  ferments  act  like  the  hyenas  of  the 
battlefield  —  appearing  and  acting  only  when  the  combat  is  over, 
devouring  the  injured  and  dead  tissues  by  protein  building,  digestion, 
and  liquefaction.  Therefore,  the  progress  of  an  acute  pyogenic  infec- 
tion cannot  be  stayed  by  preventing  the  formation  of  ferments.  On 
the  other  hand,  in  stationary  processes,  where  leukocytes  accumulate 
in  large  numbers,  formiug  proteol;)i:ic  ferments  which  constantly  pro- 
voke additional  leukoc^'tosis  and  maintain  suppuration  as  in  circum- 
scribed abscesses  and  stationary  foci  whose  granulated  tissue  wall 
denotes  the  triumph  of  reparative  genesis ;  or  in  fistulous  tracts  leading 
to  retained  necrotic  tissue  or  slightly  infected  foreign  bodies,  which 
do  not  become  encapsulated  because  of  the  action  of  the  ferments 
originating  from  prolonged  leukocytosis,  etc.,  antifermetits  serve  a 
useful  purpose. 

BIBLIOGRAPHY 

1.  Landerer.     Samml.  klin.  Vortrag.,  1885,  No.  259. 

2.  Bier.     Leipzig,  1906. 

3.  Lexer.     Therap.  d.  Gegenwart.,  1903. 

4.  Lexer.    Zeitschr.  f.  Aertz.  fortbild.,  1906. 

5.  Oberst.     Quoted  by  Hildebrand,  Berlin  klin.  Wocb.,  1906. 

6.  SCHLEICH.     Die  Deutsch.  Klinik.,  Bd.  8,  1901. 

7.  V.  Bruns.     Chir.  kong.  Verb.,  1901,  ii. 

8.  Carrel.     Jr.  A.  M.  A.,  Dee.  19,  1916. 

9.  Leriche.     Med.  &  Surg.  Tberapy.  iv,  Appleton,  K  Y.  &  Lond.,  1918. 

with  lit. 

10.  Wrede.     Arch.  f.  klin.  Chir.,  Bd.  84,  1907,  with  lit. 

11.  Klapp.    Mlinch.  med.  Wocb.,  1905. 

12.  Lexer.    Miinch.  med.  "\Yoch.,  1906. 

13.  Wrede.    Miinch.  med.  Woch.,  1910. 

14.  Zaxgemeister.     Deutsch.  med.  Woch.,  1908. 

15.  Fraxgexiieim.     Arch.  f.  klin.  Chir.,  Bd.  85,  1908. 

16.  ISELix.     Miinch.  med.  Woch.,  1909. 

17.  E.  I^IuLLER.    Zentrbl.  f.  Chir.,  1909. 

18.  KoLACZEK.     Beitr.  z.  klin.  Chir.,  Bd.  61,  1909,  also  Chir.  kong.  Verh., 

1909,  i. 

19.  Peiser.     Beitr.   z.   klin.    Chir.,   Bd.    60,   1908,  also    Chir.   kong.   Verh., 

1908.  i. 

20.  JocHMAXx  and  Batzner.    Munch,  med.  Woch.,  1908. 


CHAPTER  X 

THE  PYOGENIC  INFECTIONS   OF   THE   VAEI0U3   TISSUES 

A.     PYOGENIC  INFECTIONS  OF  THE  SKIN  AND  SUBCUTANEOUS 

TISSUE 

Furuncle. —  "When  the  pyogenic  bacteria  normally  inhabiting  the 
surface  of  the  body,  or  those  transferred  to  it  from  a  contiguous  or 
remote  focus  of  suppuration,  are  mechanically  forced  into  the  pores 
of  the  skin,  circumscribed  inflammation  occurs  (Schimmelbusch^). 
As  the  bacteria  can  be  made  to  enter  the  hair  bulbs  more  readily  than 
the  sinuous  ducts  of  the  sudoriferous  follicles,  the  sebaceous  glands  of 
the  former  are  most  frequently  the  seat  of  the  primary  infection. 

The  result  is  the  formation  of  a  circumscribed  suppurative  acute 
inflammation,  the  center  of  which  is  the  hair  follicle,  i.  e.,  the  port 
of  entrance  of  the  infection.  The  attendant  hyperemia  and  exudation 
leads  to  the  formation  of  round,  elevated,  hard,  red  nodules  varying  in 
size  from  that  of  a  pea  to  a  cherry.  The  formation  of  a  small  quantity 
of  pus  causes  elevation  of  the  epithelium  at  the  center  of  the  nodule 
corresponding  to  the  hair  follicle,  and  the  appearance  of  a  pustule. 
Evacuation  of  the  pus  is  followed  by  healing.  When  the  process  is 
extensive,  necrosis  of  tissue  follows.  The  hair  follicle  and  sebaceous 
gland  are  destroyed  by  the  bacterial  poison,  necrosis  of  contiguous 
tissue  being  proportionate  to  the  extent  of  the  inflammation.  The 
necrotic  tissue  *'  core  "  —  shaped  like  a  bowling  pin  —  is  gradually 
loosened  by  the  suppurative  process  and  expelled,  though  its  absorp- 
tion may  occur.    The  resultant  cavity  heals  by  granulation. 

This  type  of  inflammation  is  called  a  furuncle,  and  may  be  classi- 
fied as  small  or  large.  Furuncles  are  caused  by  the  various  kinds  of 
staphylococci,  though  staphylococcus  circumscriptus  cutis  is  the  one 
commonly  found  (Kocher-),  and  in  some  instances,  streptococci  are 
responsible  for  the  lesion. 

Furuncles  appear  most  frequently  on  uncxean  portions  of  the  body 
subjected  to  mechanical  irritation  (friction  from  attire),  such  as  the 
nates,  thigh,  axilla,  and  neckj  on  portions  of  the  skin  afflicted  with 

255 


256  INFECTIONS  OF  WOUNDS 

itching  that  causes  scratcliiug ;  and  often  in  crops  on  patients  whose 
resistance  is  lowered  by  exhausting  diseases  (diabetes,  cachexia  of 
various  kinds,  marasmus,  etc.)-  On  portions  of  tlie  skin  —  tlie  seat  of 
comedo  (face,  back)  — furuncles  frequently  complicate  acne.  When 
furuncle  follows  insect  stabs,  it  is  a  question  whether  this  is  due  to 
the  stab  or  provoked  b}'  scratching.  Puncture  with  a  staphylococcus 
coated  needle  is  followed  by  a  furuncle.  Because  of  the  absence  of 
hair  follicles  upon  the  palms  of  the  hands  and  soles  of  the  feet, 
furuncles  in  these  situations  are  rare. 

Extension  of  inflamniatian  from  the  site  of  a  single  furuncle  is 
uncommon,  the  lesion  remaining  circumscribed  and  promptly  healing 
after  separation  of  the  diminutive  slough.  However,  every  furuncle 
'presents  certain  elements  of  danger:  the  pus  is  frequently  transferred 
from  an  exposed  furuncle  by  means  of  poultices,  underwear,  or  the 
fingers,  and  causes  the  development  of  new  foci  of  infection,  which, 
in  cases  of  diabetes  or  general  debilitj^,  become  multiple  (furmicu- 
losis)  •  again,  it  is  possible  for  the  bacterial  excitants  to  gain  access 
to  the  lymph  channels  and  blood  passages.  The  absorption  of  toxins 
from  a  single  furuncle  is  shown  by  the  constitutional  symptoms  at 
times  attendant  upon  this  condition.  When  the  lesion  is  situated  on 
the  hands  or  the  feet,  where  the  movements  of  the  joints  promote  the 
transmigration  of  bacteria  into  the  lymphatics,  lymphangitis  and 
lymphadenitis  frequently  occur.  Contamination  of  the  blood  current 
follows  invasion  by  the  aggressors,  in  part  through  the  capillaries 
and  arterioles,  which  proliferate  in  the  inflammatory  focus  and  are 
traumatized  by  rough  manipulations  (squeezing  after  incision,  suc- 
tion treatment),  and  in  part  by  means  of  thromhophletitis  in  a  con- 
tiguous large  vein  (vena  facialis,  saphenous).  Consequently  every 
furuncle  may  become  gravely  menacing  as  the  result  of  complicating 
bacteremia  and  the  formation  of  metastases. 

Carbuncle. —  Carbuncle  (really  a  severe  form  of  furuncle)  is  more 
frequently  attended  by  complications  than  is  furuncle.  A  carbuncle 
is  characterized  by  the  simultaneous  infection  of  a  number  of 
contiguous  hair  follicles,  and  is  accompanied  with  severe  pain  and 
swelling,  rapid  extension,  massive  necrosis,  high  temperature,  and 
serious  general  disturbances.  The  inflammatory  infiltrate  is  deep  red 
cr  purple  in  color,  is  often  elevated  above  the  skin  level  (1-2  mm.),  is 
surrounded  hy  a  bright  red  zone  w^hich  generally  merges  into  the 
adjacent  skin,  and  presents  at  its  center  pustules  and  necrotic  plugs, 
seropurulent  scabs,  and  gangrenous  patches.     By  extension  of  inflam- 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     257 

mation,  the  process  develops  new  furuncles,  and,  if  not  arrested, 
rapidly  spreads,  often  reaching  (in  one  of  two  weeks)  the  size  of  an 
adult  s  hand  or  that  of  a  small  plate,  and  not  infrequently  invading 
with  infiltration  and  necrosis,  the  tissues  down  to  the  muscle  fascia. 
The  center  of  the  carbuncle  sloughs  to  the  extent  of  its  depth,  the 
fascia  at  times  becoming  necrotic.  Extensive  subcutaneous  or  deeply 
located  carbuncles  spread  by  thronihopJdchitis  (infection  of  the  upper 
lip  through  the  angular  facial  vein,  superior  ophthalmic  vein,  and 
cavernous  sinus,  to  the  brain),  and  may  cause  pyogenic  general  infec- 
tion. Superficial  lympJiangitis  almost  always  complicates  carbuncles 
of  the  extremities.  The  contiguous  lymph  nodes  often  suppurate. 
In  feeble  persons,  or  in  diabetics,  prolonged  carbunculosis  may  termi- 
nate fatally  without  the  occurrence  of  meningitis,  metastases,  etc. 

Cartiincles  develop  partly  as  the  result  of  a  special  disposition  (for 
instance,  diabetic),  and  partly  because  of  the  virulence  of  the  causative 
bacteria.  Besides  staph! yococci,  many  other  varieties  of  pyogenic 
organisms,  especially  streptococci,  are  found  capable  of  provoking  car- 
buncle (Kocher-).  Frequently,  however,  carbuncle  develops  when  a 
furuncle  is  manipulated  by  the  patient  himself,  or  when  subjected  to 
the  application  of  poultices  which  macerate  the  surrounding  skin, 
creating  conditions  favorable  to  the  transfer  and  colonization  of  bac- 
teria. 

Harmless  forms  of  furuncle  are  those  limited  to  a  single  hair  follicle 
and  its  sebaceous  gland  {follwulitis) .  Small  pustules,  attended  with 
slight  infiltration,  frequently  appear  in  the  hairy  areas  of  the  skin. 
Avulsion  of  the  hair  is  promptly  followed  by  healing.  When  the 
process  extends  from  hair  to  hair,  the  rather  obstinate  condition 
designated  as  folliculitis  harhae  (barber's  itch)  is  established.  Under 
these  conditions  the  application  of  tincture  of  iodin  satisfactorily 
takes  the  place  of  the  more  tedious  extraction  of  the  hairs. 

Folliculitis  commonly  complicates  the  presence  of  comedo  on  the 
face  and  shoulders.  The  dirt  obstructed  secretory  ducts  of  the  seba- 
ceous glands  dilate  the  exit  ports  of  the  fine  lanugo  hairs,  and  render 
easy  the  entrance  of  infective  bacteria.  Expulsion  of  the  comedo  with 
the  fingers  fertilized  by  contiguous  pustules  is  the  most  common  cause 
of  folliculitis.  The  "  dirt  plug  "  surrounding  these  small  red  fur- 
uncles has  caused  the  condition  to  be  called  ocne  punctata;  when  pus 
forms,  the  term  acne  pustulosa  is  used.  Folliculitis,  located  in  cilia 
and  their  sebaceous  glands  (Meibomian  glands),  is  called  hordeolum. 
Healing  quickly  follows  evacuation  of  the  pus,  though  forcible  evacu- 


258  INFECTIONS  OF  WOUNDS 

atioii  (by  pressure)  tends  to  reinfection  and  persistence  of  the  condi 
tion.     Execution  of  the  principles  laid  down  above  in  connection  with 
the  treatment  of  pyogenic  inflammation   (though  in  miniature)   will 
result  in  relief. 

Furuncles  that  take  on  the  form  of  severe  carbuncles  with  extensive 
infiltration,  rapid  extension,  and  massive  necrosis,  must  be  differen- 
tiated from  anthrax.  Microscopical  examination  of  the  exudate  should 
make  the  diagnosis. 

The  treatment  of  furuncle  is  directed  toward  rapid  healing  and  the 
prevention  of  the  development  of  new  inflammatory  foci. 

When  the  furuncle  is  located  in  a  portion  of  the  body  subjected  to 
friction,  the  area  should  be  protected  by  a  covering  of  gauze,  coated 
with  salve  and  held  in  place  by  adhesive  plaster,  to  obviate  the 
mechanical  transference  of  pus  to  contiguous  parts.  The  salve  pre- 
vents the  formation  of  a  scab  which  would  interfere  with  drainage. 
Often  this  simple  treatment  (even  in  carbuncle  of  the  face)  is  fol- 
lowed by  recovery.  If,  despite  spontaneous  or  therapeutic  emptying  of 
the  pustule,  infiltration  extends  and  the  local  and  constitutional  mani- 
festations progress,  immediate  liberal  incision  is  imperatively  indicated. 

After  disinfection  of  the  skin,  and  local  anesthesia  with  ethyl 
chlorid,  the  focus  is  incised  to  the  extent  of  the  inflammatory  infil- 
trate. Forcible  removal  of  the  necrotic  central  "core"  (with  forceps 
or  curette)  is  to  be  avoided.  The  incision  should  be  lightly  tamponed 
with  sterile  or  iodoform  gauze.  At  the  end  of  twenty-four  hours, 
when  the  tampon  is  removed,  the  spontaneously  separated  "  core  " 
will  often  be  found  adherent  to  it.  This  treatment  results  in  com- 
plete recovery  from  most  (at  times  severe)  furuncles.  After  the 
"  core  "  is  expelled,  the  wound  is  dressed  with  gauze  or  sheet  lint 
spread  with  salve.  At  each  change  of  dressing,  the  contiguous  skin  is 
cleansed  with  95  per  cent  alcohol. 

Moist  dressings  and  poultices  accomplish  rapid  softening  of  the 
furuncle;  their  use  is,  however,  ohjectio7ial)le  for  the  reasons  already 
stated  in  connection  with  the  treatment  of  pyogenic  infections  (p.  241). 

Simple  incision  does  not  achieve  the  desired  result  in  cases  of  large 
furuncle  or  carbuncle.  The  patient  should  be  narcotized,  and,  after 
skin  disinfection,  the  infected  area  is  widely  sectioned,  employing  a 
crucial  incision  for  the  purpose.  The  four  resultant  flaps  are  held 
apart  with  retractors  and  dissected  up  to  the  edges  of  the  infiltrate, 
exposing  the  entire  focus;  the  necrotic  corners  of  the  flaps  should  be 
ablated,  a  measure  which  permits  of  the  free  drainage  of  pus  and 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     259 


facilitates  egress  of  necrotic  tissue.  After  the  sloughing  "  cores  " 
have  been  gently  removed,  and  spurting  vessels  deligated,  the,  now 
widely  gaping,  wound  is  lightly  tamponed  with  iodoform  gauze.  The 
tampon,  which  is  gradually  loosened  by  wound  secretions,  is  removed 
at  the  end  of  fort^'-eiglit  hours  when  granulation  usually  has  begun. 
At  the  end  of  one  to  two  weeks  of  salve  treatment,  repair  and  epi- 

dermization  is,  as  a  rule, 
accomplished.  Cicatriza- 
tion is  often  followed  by 
considerable  contraction. 
InsutJicient  incision  does 
not  attain  the  desired  re- 
sult. 

If  thromhophlehitis  of 
large  contiguous  veins  oc- 
curs, these  must  be  cen- 
trally deligated,  opened, 
and  emptied  (purulent 
thrombosis  of  the  jugular 
or  saphenous  veins) . 

Delay  in  operative  ef- 
fort at  relief  may  permit 
tlie  development  of  fa- 
tal general  infection 
(through  the  blood  cur- 
rent) and  of  suppurative 
meningitis  (through  the 
lymph  channels).  Free 
incision  has  been  re- 
garded as  involving  the 
danger  of  general  infec- 
tion; this  is,  however,  not 
the  case,  unless  the  oper- 
ative attack  is  attended  with  violent  trauma  (warned  against  in  con- 
nection with  the  treatment  of  pyogenic  infections). 

Widely  disseminated  furunculosis  is  likely  to  present  a  difficult 
problem;  however,  carefully  executed  operative  measures,  frequent 
thorough  cleansing  of  the  skin,  stimulating  baths,  frequent  changes  in 
underwear,  and  the  daily  renewal  of  dressings  of  open  furuncles,  if 


Fig.    123. —  Granflating    Wound    Xine    Days 
After  Operative  Treatment  of  Carbuncle. 


260  INFECTIONS  OF  WOUNDS 

patiently  persisted  in,  will  ultimately  achieve  its  solution.  The  use 
of  salves  and  plasters  is  likely  to  spread  infection  to  contiguous  skin, 
surfaces.  If  the  furunculosis  is  restricted  to  a  certain  region,  this 
may  —  for  a  single  sitting  —  be  subjected  to  the  application  of  a 
5  per  cent  formalin  solution  pack,  which  may  remain  in  situ  for  sev- 
eral hours,  or  the  surface  may  be  repeatedly  painted  with  tincture 
of  iodin. 

The  general  condition  of  the  patient  (especially  a  diabetic)  should 
receive  attention. 

The  Subcutaneous  Abscess. —  All  deeply  located  suppurative  inflam- 
mations may  lead  to  focal  collections  of  pus  in  the  skin  and  sub- 
cutaneous tissues.  Abscesses  of  the  skin  are  rarely  limited  to  this 
situation,  but  usually  extend  to  the  subjacent  cellular  tissue.  The 
suppurative  exudate  of  furuncle;  the  purulent  collections  complicat- 
ing erysipelas,  lymphangitis  and  suppurative  phlegmo7i;  the  pus  ori- 
ginating in  cavities,  in  joints,  in  hones,  and  in  muscles ;  and  that  ex- 
tending from  other  deeply  located  foci,  invade  the  loosely  meshed 
subcutaneous  tissue. 

Subcutaneous  hematomata  (traumatic),  when  infected  by  ectogen- 
ous,  lymphogenous,  or  hematogenous  pus  cocci,  suppurate  and  abscess 
formation  results. 

Metastatic  abscesses,  when  widely  distributed,  frequently  develop 
in  subcutaneous  tissue  in  conjunction  with  those  occurring  in  joints, 
muscles  and  organs.  Abscesses  of  this  sort  are  most  frequently  caused 
by  staphylococci,  though  -in  some  instances  the  bacillus  typhosus  (ty- 
phoid fever)  is  the  causative  excitant. 

Subcutaneous  abscess  is  characterized  by  swelling,  redness  and  ten- 
sion of  the  skin;  pain,  heat  and  fluctuation.  It  is  located  within  a  hard 
infiltrated  zone  and  accompanied  with  moderate  fever.  Sooner  or 
later  the  skin  at  the  center  of  the  zone  thins,  becomes  bluish  in  color, 
ruptures,  and  spontaneous  evacuation  of  pus  occurs.  This,  in  small 
abscesses,  is  soon -followed  by  recession  of  the  inflammator}^  infiltrate 
and  healing.  The  longer  pus  is  retained,  the  thicker  is  the  surrounding 
granulation  tissue  (the  abscess  membrane  consists  of  an  outer  layer 
of  connective  tissue,  and  an  inner  lining  of  granulation  tissue)  which 
is  inhabited  by  numerous  pus  excitants,  whose  activities  are  respons- 
ible for  the  persistence  of  pus  forming  cavities  and  fistulae.  When  all 
necrosed  tissue  is  expelled,  and  the  bacteria  are  discharged  or  dead, 
coalescence  of  the  walls  of  the  abscess  area  results  in  cicatrization. 

When  purulent  exudates  become  localized,  the  process  usually  may 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     261 

be  regarded  as  no  longer  possessed  of  danger ;  if,  however,  the 
abscess  membrane  suddenly  ruptures,  either  spontaneously  or  as  the 
result  of  trauma  (massage,  etc.),  reextension  of  the  process  with 
invasion  of  the  lymph  and  blood  channels  may  occur. 

Free  incision  and  drainage  of  subcutaneous  abscesses  is  promptly 
followed  by  healing. 

Subcutaneous  Phlegmon. —  The  term  phlegmon  is  derived  from  the 
Greek — phlego,  meaning  "burn."  The  condition  may  be  described 
as  aji  extending  inflammation  which,  when  due  to  pj'ogenic  bacteria, 
becomes  purulent,  and,  when  caused  by  putrefactive  organisms,  is 
attended  with  gas  formation.  The  lesion  is  located  in  the  cellular 
tissue  beneath  the  skin,  and  in  the  interspaces  between  muscles,  fascia, 
and  organs  (deep  phlegmon).  When  superficial,  the  process  shows  a 
tendency  to  extend  inward,  and  when  located  deepl}^  proliferates  in 
the  direction  of  least  resistance,  a  characteristic  which,  at  times,  is 
sufficiently  intricate  to  make  the  site  of  inception  difficult  to  recognize 
(for  instance,  mediastinal  inflammation  due  to  extension  of  a  process 
in  the  neck).    Cellulitis  and  phlegmonous  inflammation  are  identical. 

Phlegmon  of  the  fingers  and  toes  is  called  panaritium,  and,  in  accord 
with  the  extent  of  involvement,  is  further  characterized  as  panaritium 
subepidermoidale,  subcutaneum,  tendinosum,  articulare,  and  os-sale. 
Phlegmons  of  the  periosteum  and  of  the  bone  marrow  are  identical 
with  suppurative  periostitis  and  osteomyelitis. 

Like  all  phlegmonous  processes,  subcutaneous  inflammations  are  due 
to  pyogenic  infection  following  trauma,  or  are  of  metastatic  origin. 
They  invade  either  the  deep  tissues  hij  extension  or  the  reverse  ob- 
tains, and  deeply  located  infections  extend  to  the  subcutaneous  tissues. 

In  accord  with  the  character  of  exudate  and  the  extent  of  necrosis, 
phlegmonous  inflammations  are  designated  as  serous,  purulent,  and 
necrotic,  though  frequent  variations  in  this  regard  do  not  always  per- 
mit of  a  distinctive  classification. 

The  development  of  phlegmon  presupposes  invasion  of  the  suhcu- 
ianeous  tissues,  the  skin  and  fascia  being  only  secondaril}^  involved. 
Staphylococci  and  streptococci,  alone  or  together,  are  most  frequently 
the  causative  bacterial  excitants.  The  severest  forms  of  phlegmon  are 
provoked  by  pyogenic  streptococci  (alone  or  associated  with  other 
bacteria),  especially  when  transferred  from  yuan  to  man.  For  this 
reason,  wounds  received  during  autopsies  upon  fresh  cadavers — in 
which  death  resulted  from  acute  suppurative  peritonitis,  meningitis, 


262  INFECTIONS  OF  WOUNDS 

or  general  infection,  are  most  likely  to  be  followed  by  severe  pMeg- 
monous  inflammations. 

Phlegmonous  inflammation  is  characterized  by  rapidly  developing 
pain,  swelling,  and  redness  of  the  slin,  associated  with  inflammatory 
edema  of  surrounding  parts,  and  grave  constitutional  symptoms.  The 
last  are  usually  ushered  in  by  a  chill  followed  by  a  sharp  rise  of  tem- 
perature which,  at  first,  is  continous  in  character,  and  later,  when 
general  infection  is  developed,  becomes  irregular,  being  lower  in  the 
morning.  The  contiguous  lymph  nodes  are  always  palpable,  painful 
and  swollen.  Purulent  lymphadenitis,  lymphangitis  of  the  superficial 
vessels,  and  thromhophlehitis  of  the  subcutaneous  veins,  occur  in 
most  instances,  though  these  may  also  be  the  cause  of  the  phlegmon. 
The  presence  of  the  bacterial  excitants  may  frequently  be  detected 
in  the  blood  (see  surgical  hematology). 

Phlegmonous  processes  may  be  circumscribed  or  diffuse.  The  for- 
mer, though  primarily  attended  with  severe  manifestations,  soon 
become  stationary  as  the  result  of  the  bactericidal  action  of  the  tis- 
sues. In  siibacute  or  chronic  infections  single  or  multiple  abscesses 
are  surrounded  by  thick  layers  of  granulation  tissue  which  has  a 
tendency  to  prevent  the  spread  of  the  infiltration.  Trauma  or  rough 
handling  (massage)  may  cause  invasion  of  the  surrounding  tissues. 

Diffuse  phlegmons  progressively  extend  to  the  contiguous  tissues, 
unless  the  infected  area  is  unburdened  of  its  inflammatory  products 
and  bacteria  by  free  incision  and  drainage.  In  some  instances  of 
acute  infection,  the  entire  limb  and  a  portion  of  the  trunk  may  be  in- 
volved. 

The  character  of  these  widely  divergent  manifestations  depends 
upon  the  virulence  of  the  aggressors,  the  local  resistance  of  the  tis- 
sues, and  the  general  condition  of  the  host.  Restricted  phlegmon 
usually  occurs  in  healthy  individuals,  while  the  diffuse  form  frequently 
attacks  those  whose  tissue  resistance  is  lessened  (by  trauma),  or  those 
afflicted  with  exhausting  diseases  (diabetes,  marasmus,  tuberculosis, 
etc.). 

However,  localization  and  diffusion  often  occur  with  interchanging 
sequence.  As  a  rule,  early  incision  and  drainage'  of  a  spreading  phleg- 
mon is  followed  by  localization,  though,  unfortunately,  these  measures 
are  not  always  productive  of  this  desirable  result. 

Incision  shows  the  skin  and  subcutaneous  tissues  to  be  heavily 
infiltrated  with  serous  exudate  which  oozes  out  of  the  opening  in  con- 
siderable quantity.     Small,  soft,  widely  separated  pus  collections  may 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      263 

be  present.  The  mild  forms  of  phlegmon,  which  soon  localize  and 
suppurate,  are  characterized  by  the  appearance  of  serous  exudate. 
Though  the  diffuse  form  of  inflammation  is  also  attended  with  serous 
exudate,  necrosis  of  tissue  frequently  occurs  without  the  formation 
of  pus.  The  subeutis,  large  areas  of  the  skin,  of  fascia,  and  the 
tendons,  are  sequentially  destroyed,  while  the  overwhelmingly  in- 
fected body  gradually  succumbs.  Except  for  the  absence  of  putre- 
faction, this  clinical  picture  is  not  unlike  that  presented  by  Pirogoff 
when  describing  acute  purulent  edema. 

Frank  suppurative  phlegmon  presents  a  less  virulent  picture,  be- 
ginning with  the  formation  of  serous  exudate,  followed  on  the  second 
day  by  suppuration.  If  the  infected  zone  is  incised  at  this  time, 
necrosis  is  slight,  usually  restricts  itself  to  the  subcutaneous  tissue,  is 
promptly  encapsulated,  and  is  rapidly  followed  by  recession  of  the 
inflammation.  Delayed  or  insufficient  incision,  the  application  of 
poultices  and  the  use  of  inunctions  (mercury,  iodin,  etc.)  favor 
extension  of  the  phlegmon  (after  necrosis  of  the  subjacent  fascia)  into 
the  interspaces  of  the  soft  parts,  bones  and  joints,  and  the  develop- 
ment of  general  infection. 

In  a,ll  forms  of  phlegmon,  liberal  incision  and  adequate  drainage 
make  possible  the  avoidance  of  farther  extension  and  the  arrest  of 
general  infection.  Under  narcosis,  and  after  exsanguination  of  the 
part,  the  incisions  are  made  to  penetrate  deeply  and  smoothly  into 
the  tissues,  opening  widely  the  intermuscular  spaces  and  to  provide  for 
counter  drainage.  Soon  after  the  operative  attack,  the  fever  falls  but 
may  rise  again  if  the  incisions  do  not  accomplish,  the  purpose,  when 
pus  is  retained,  if  infection  still  extends,  or  when  the  wound  is  me- 
chanically irritated  during  dressings  (see  ''  Principles  of  Treatment," 
p.  239).  If  the  process  is  receding,  leukocytosis  and  bacteriemia  dis- 
appear in  a  few  days. 

The  dangers  of  phlegmon  lie:  First,  in  its  extension  to  important 
regions  by  means  of  thrombo-phlebitis  involving  the  meninges,  the 
mediastinum,  etc. ;  second,  in  the  loosening  of  purulent  clots  (emboli) 
and  their  deposit  in  distant  organs,  causing  abscesses  of  the  lungs, 
liver,  kidney,  etc. ;  and  third,  in  the  invasion  of  the  blood  (bacteriemia) 
with  its  dire  results.  An  extending  phlegmon  of  a  limb,  not  arrested 
by  incision,  terminates  fatally  unless  amputation  is  resorted  to  (v. 
Bergmann^),  Execution  of  the  amputation  is  indicated  by  the  sever- 
ity and  rapidity  of  extension  of  the  local  process ;  the  appearance  of 
bacteria  in  the  blood,  and  the  maintenance  and  progression  of  grave 


264  INFECTIONS  OF  WOUNDS 

constitutional  manifestations.  It  is  true  that  the  mortality  of  the 
procedure  is  heavy,  yet  recovery  occurs  with  sutScient  frequency  to 
justify  the  attempt. 

In  other  regards,  the  treatment  of  phlegmon  does  not  differ  from 
that  described  under  the  head  of  acute  purulent  infections  (p.  239). 
Rest  in  hed  until  the  temperature  is  normal  is  essential.  Large  granu- 
lating surfaces,  following  extensive  sloughing,  may  be  subjected  to 
transplantation  of  skin.  Contractures  should,  as  far  as  is  possible, 
be  avoided  by  posture  and  by  careful  movements  of  the  part.  When 
deformity  follows,  the  treatment  lies  along  the  lines  laid  down  in  the 
principles  of  plastic  surgery. 

Erysipelas. —  Erysipelas  (from  the  Greek  —  meaning  red  skin)  has 
long  been  recognized  as  an  infectious  surgical  disease.  It  may  be 
characterized  as  an  acute,  extending,  reddening  of  the  skin  or  mucosa 
attended  with  high  fever. 

The  direct  causative  excitant  in  erysipelas  was  discovered  by 
Fehleisen*  (1881  —  cultured  in  1883),  who  gave  it  the  name  of  strep- 
tococcus erj^sipelatus.  For  a  long  time  it  was  regarded  as  solely 
responsible  for,  so-called,  erysipelas,  but  later,  especially  as  the  result 
of  the  work  of  Petrusehky,^  it  was  shown  that  a  special  streptococcus 

WHICH  WAS  THE  SPECIPIC  CAUSE  OF  ERYSIPELAS  DID  NOT  EXIST    (p.  197). 

This  explains  why  wounds  contracted  during  operations,  or  at  autop- 
sies, devdlop  erysipelas  irrespective  of  the  kind  of  pus  thus  transferred, 
and  why  the  incision  of  a  streptococcus  phlegmon  is,  at  times,  followed 
by  this  disease.  The  causative  relationship  between  streptococci  and 
erysipelas  is  also  shown  by  its  occurrence  in  puerperal  fever  —  the 
newborn  of  a  mother  thus  infected  frequently  developing  erysipelas 
(which  begins  at  the  navel)  and  the  attendant  often  showing  an 
erj^sipelatous  infection  of  an  injured  finger.  Per  contra,  puerperal 
fever  frequently  develops  in  obstetrical  cases  where  the  midwife 
previously  has  come  in  contact  with  erysipelas  or  been  afflicted  with  it. 

The  epidemics  of  erysipelas  occurring  in  hospitals,  in  pre-aseptic 
days,  may  be  explained  by  the  fact  that  streptococci  are  widely  dis- 
tributed, and  were  no  doubt  conveyed  from  bed  to  bed  by  instruments, 
dressings,  etc.,  and  the  hands  of  operators  and  their  assistants  who 
handled  cases  of  virulent  streptococcus  phlegmon.  The  theory  that 
the  exfoliations  of  skin  in  erysipelas  contain  streptococci,  and  that  by 
this  means  the  infection  is  conve^-ed  through  the  air,  has  been  proven 
fallacious  by  Respinger®  and  others. 

The  occurrence  of  erysipelas  depends  upon:    First,  the  presence  of 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     265 

a  strain  of  streptococcus  of  sufficient  virulence  to  overcome  the  bac- 
tericidal capacity  of  the  tissues ;  and,  second,  their  entrance  into  the 
lymph  spaces  of  the  skin  or  mucosa  where,  in  from  one  to  two  days 
(Fehleisen's  experiments  make  it  from  fifteen  to  sixty-one  hours  after 
inoculation),  primary  local  disturbances  are  provoked. 

In  rare  instances,  staphylococci  (Jordan,'^  Jochmann^),  the  bacillus 
typhosus  (Rheiner''),  and  pneumococci  have  been  found  to  be  the 
causative  excitants  in  cases  of  skin  infections  not  unlike  erysipelas. 
Some  of  the  cases  terminated  fatalHy. 

Invasion  of  the  skin  or  mucosa  occurs  in  three  ways,  being  ecto- 
genoiis,  lijmpJiogenous,  or  hematogenous  in  origin. 

The  ectoge7ious  form  is  by  far  the  most  frequent.  An  epithelial 
defect  is  the  invariable  port  of  entrance,  irrespective  of  the  presence 
of  an  accidental  or  surgical  solution  of  continuity  of  the  surface. 
Ingress  is  accomplished  through  rhagades,  ulcers,  minute  defects  in 
the  skin  or  mucosa,  and  also  through  fresh  or  old  wounds.  Coaptated 
and  granulating  wounds  are  readily  invaded  through  small  openings 
or  as  the  result  of  ^ight  trauma.  This  is  especially  true  of  old  ulcers 
of  the  leg. 

Lgmpliogenous  erysipelas  is  the  result  of  the  extension  of  a  deeply 
located  inflammation  into  the  superimposed  lymph  channels.  Usually 
the  red  streaks  of  streptococcus  lymphangitis  appear  at  a  situation 
distant  from  the  port  of  entrance,  and  either  precede  the  course  of  the 
extending  deeper  process  or  follow  it.  In  some  instances  of  ruptured 
purulent  osteomyelitis  or  empyema  of  a  joint,  the  skin  opening  is  sur- 
rounded by  a  frank  erysipelas,  instead  of  a  faint  superficial  redness 
usually  present  under  these  conditions. 

Hematogenous  erysipelas  is  rare.  It  occurs  as  a  part  of  the  general 
metastatic  manifestation  common  to  streptococcemia  originating  in 
phlegmon,  purulent  joints,  etc. 

While  Jxewatogenous  erysipelas  may  appear  at  any  portion  of  the 
body,  and  the  lymphogenous  form  is  dependent  upon  the  presence  of 
deep  phlegmon,  ectogenous  erysipelas  (excluding  the  infrequent 
instances  of  infection  of  wounds)  occurs  most  frequently  upon  the 
face.  In  Roger's  collection  of  597  cases,  496  occurred  on  the  face, 
and  69  on  the  face  and  scalp.  This  is  explainable  on  the  ground  that 
the  face  presents  numerous  ports  of  entrance  in  the  form  of  rhagades, 
eczematous  patches,  and  small  wounds  —  especially"  at  the  nostrils  and 
lips;  that  the  secretions  of  the  nose  frequently  contain  streptococci, 
and  that  the  face  is  often  subjected  to  friction  with  contaminated 


266  INFECTIONS  OF  WOUNDS 

fingers.  To  this  may  be  added,  that  most  cases  of  erysipelas  of  the 
mucous  membranes  invade  the  face  by  way  of  the  nostrils  and  nasal 
tear  duct,  or  through  the  auditory  canal. 

The  local  pathogenesis  consequent  to  streptococcus  invasion  of  the 
skin  is  that  of  an  acute  serous  inflammation  of  all  its  layers,  which  at 
times  is  attended  with  the  formation  of  pus.  The  subcutaneous  tissue 
is  involved  to  a  varying  degree ;  when  the  hyperemia  is  severe,  serous 
exudation  and  the  migration  of  leitkocytes  into  its  loose  meshes  occur. 
As  the  cocci  multiply  within  the  13'mph  channels,  those  located  at  the 
edges  of  the  process  are  filled  with  the  organisms,  while  the  blood 
vessels  are  invaded  only  in  the  hematog-enous  form  of  the  disease  or, 
in  instances  of  general  infection,  accompanied  with  bacteremia.  In 
inflammations  unattended  with  pus  formation,  necrosis  of  tissue  is 
exceedingly  slight;  recession  of  the  process  —  which  occurs  in  a  few 
days  or  a  week  —  is  not  followed  by  any  discernible  evidence  other 
than  the  exfoliation  of  epidermis  and  falling  of  the  hairs.  The  latter 
is  the  result  of  exudation  in  the  hair  follicles,  though  the  hairs  grow 
again.  In  severe  forms  of  erysipelas  and  in  situations  in  which  the 
skin,  owing  to  the  absence  of  fat,  lacks  distensibility  (over  the  shin 
bones,  patella,  olecranon,  ilium,  etc.),  or,  because  of  its  loose  attach- 
ment, permits  of  massive  exudation  (eyelids,  etc.),  necrosis,  at  times, 
occurs.  Necrosis  of  tissue  is,  however,  most  frequent  in  the  purulent 
phlegmonous  type  of  erysipelas. 

The  "beginning  of  erysipelas  is  expressed  by  the  appearance  of  red, 
hot,  burning  or  itching  spots  on  the  skin  which  is  thickened  and  tender 
to  the  touch.  Chill  and  a  sharp  rise  of  temperature  precede  or  accom- 
pany these  manifestations  which  are,  in  a  few  hours,  followed  by  a 
sharply  defined  reddening  and  swelling  of  the  skin.  The  rapidly 
spreading  borders  of  the  inflamed  area  follow  Langer's  lines  of  cleav- 
age and  the  connective  tissue  furrows  of  the  corium  (Kocher^°), 
chiefly  in  the  direction  of  the  lymph  stream,  though  occasionally 
against  it.  The  zone  of  infection  does  not  spread  symmetrically,  but 
sends  forth  dark,  red,  arched  protrusions  and  tongue  or  spear  shaped 
projections  standing  out  in  marked  contrast  to  the  intervening  older 
paled  areas.  The  advance  of  the  process  varies  greatly  in  rapidity,  at 
times  spreading  slowly  and  at  others  involving  the  entire  face  in  a 
day.  Where  the  skin  is  firmly  attached  (chin,  border  of  hair,  crest 
of  ilium,  etc.),  the  inflammation  often  halts  suddenly,  leaving  unaf- 
fected many  areas  which  appear  like  white  islands  in  the  surrounding 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      267 

redness.  "When  the  loose  connective  tissue  of  the  eyelids  or  of  the 
external  genitals  is  involved,  it  is  distended  with  edematous  infiltrate. 

The  classification  of  erysipelas  may  not  be  based  definitely  upon  the 
clinical  manifestations  of  its  various  forms,  since  these  frequently 
merge  into  one  another.  However,  the  terminology  most  commonly 
employed  in  this  connection  may  be  stated  as  follows :  Erysipelas 
crythematosum,  with  strongly  marked  redness;  hulhosum,  with  serous 
blebs;  pustulosum,  with  purulent  blebs;  phlegmonosum,  with  subcu- 
taneous suppuration;  and  necroticans,  with  gangrene  of  the  skin. 
The  simplest  characterization  is  that  of  purulent  or  nonpurulent 
er^-sipelas,  and  is  perhaps  most  indicative  of  the  virulence  of  the 
process,  the  latter  form  being  attended  with  tissue  necrosis,  thrombo- 
phlebitis, and  general  infection. 

The  duration  of  the  disease  averages  from  six  to  ten  days,  though  in 
some  instances  of  erysipelas  of  the  extremities,  attended  with  lymphan- 
gitis, recession  has  occurred  within  twenty-four  hours.  Erysipelas  of 
the  face  and  scalp  is  rarely  of  more  than  seven  days'  duration.  When, 
however,  the  affliction  extends  from  the  face  or  from  an  extremity  to 
the  trunk,  it  persists  longer.  Once  the  trunk  is  attacked,  the  disease 
creeps  rapidly  in  all  directions  and  tends  to  recur  in  places  already 
healed.  Under  these  conditions  death  from  exhaustion  may  occur 
(erysipelas  migrans). 

Recurrence  of  erysipelas  means  the  development  of  a  new  attack, 
not  an  exacerbation  of  symptoms  after  a  few  days  of  relative  quies- 
cence. The  former  occurs  as  the  result  of  reinfection  through  a  port- 
of  entrance  that  failed  to  heal.  These  ports  are  fistulae  leading  to 
tuberculous  foci;  ulcers  of  all  kinds  (skin  tuberculosis,  syphilis,  carci- 
noma, rodent  ulcer,  etc.)  ;  rhagades  and  chronic  eczema.    As  recovery 

FROil   AX   ATTACK   DOES   NOT    PRODUCE   IMMUNITY,    and   the   StrcptOCOCci 

(though  of  lessened  resistance)  still  inhabit  the  skin  at  the  sites  desig- 
nated above,  comparatively  slight  mechanical  irritation  opens  the 
lymph  spaces  and  a  new  invasion  takes  place.  This  is  called  habitual 
erysipelas,  which  frequently  occurs  upon  the  face  where  the  conditions 
are  exceedingly  favorable  to  its  development.  Probably  an  underlying 
lack  of  resistance  to  streptococci  is  peculiar  to  patients  habitually 
subjected  to  this  disease. 

In  addition  to  redness  and  swelling  of  the  skin,  erysipelas  is  attended 
with  painful  enlargement  of  contiguous  lymph  nodes,  and  the  appear- 
ance of  red  streaks  denoting  lymphangitis.  As  a  rule,  these  manifes- 
tations disappear  without  the  formation  of  abscesses,  though,  at  times, 


268  INFECTIONS  OF  WOUNDS 

suppuration  occurs.  Abscesses  develop  in  the,  so-called,  purulent 
form  of  the  disease,  and  may  be  due  to  mixed  infection  with  staphylo- 
cocci. Phlehitis  of  the  subcutaneous  veins  of  the  legs  is  not  an  uncom- 
mon complication,  and  is  attended  with  thrombosis,  a  condition  favor- 
able to  bacterial  invasion.  Detachment  of  a  portion  of  the  clot  may 
lead  to  the  formation  of  metastases  (embolic),  and  the  development  of 
general  infection. 

The  inception  of  the  disease  is  attended  by  a  chill  and  a  sJiarp  rise 
of  temperature  — ^0-4:1° C.  ( 104-105.8 °F.) —soon  followed  by  sys- 
temic disturbances.  When  the  process  extends  symmetrically,  the 
fever  is  continuous  in  character,  and  falls,  by  either  crisis  or  lysis, 
when  the  infection  is  overcome.  When  periods  of  rest  alternate  with 
progression,  the  temperature  become  remittent  or  intermittent  in 
character.  The  systemic  disturbances,  i.  e.,  increased  pulse  rate,  vom- 
iting, delirium,  etc.,  vary  in  degree,  but,  being  due  to  the  action  of 
bacterial  poisons,  are  always  present.  Facial  erysipelas,  and  that  of 
the  scalp,  is  attended  with  marked  cerebral  disturbances  simulating 
meningitis,  the  latter  fortunately  being  a  rare  complication,  though 
it  at  times  occurs  as  the  result  of  extension  of  the  process  through  the 
orbital  veins.  In  rare  instances,  erysipelas  (usually  the  habitual) 
occurs  without  fever. 

Bacteriemia  is  infrequent,  streptococci  being  rarely  found  in  the 
blood  (Pfuhl,"  v.  Noorden^-).  The  aggressors  probably  undergo  dis- 
solution in  the  lymph  nodes,  and  those  that  gain  access  to  the  blood 
are  soon  destroyed.  They  are  rarely  found  in  the  blood  on  autopsy. 
In  cases  of  severe  overwhelming  infection,  with  metastatic  involve- 
ment, the  presence  of  streptococci  in  the  blood,  either  alone  or  together 
with  other  bacteria,  may  be  demonstrated. 

The  complications  of  erj^sipelas  arise  as  the  result  of  extension  and 
the  establishment  of  metastases.  Involvement  of  the  deeper  tissues 
gives  rise  to  parotitis,  purulent  tendosynovitis,  arthritis,  hursitis,  and 
suppuration  in  the  fatty  tissue  of  the  orlit  which  may  extend  to  the 
cranial  cavity.  Infections  of  the  mucosa  of  the  pharynx  may  extend 
to  the  larynx  (causing  obstruction),  the  trachea,  bronchi,  and  the 
lung.  The  lung  is  more  likely  to  be  invaded  through  the  blood  stream 
(embolic).  Fleuritis  is  due  to  extension  from  an  embolic  focus  in  the 
iung.     Endocardial  invasion  is  rare. 

Sequential  to  erysipelas,  the  heart's  action  is  often  seriously  im- 
paired, due  no  doubt  to  the  action  of  the  bacterial  poisons,  though 
myocardial  degeneration  is  rare.     Transient  acute  nephritis  frequently 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     269 

occurs.  Serious  kidney  complications  develop  when  these  organs  have 
already  undergone  organic  changes.  Repeated  attacks  of  erysipelas 
render  the  skin  easily  irritated  and,  at  times,  cause  permanent  thick- 
ening of  the  connective  tissue  with  lymphatic  obstruction  and  edema 
(pachyderma  of  the  face  —  Friederich^^  —  elephantiasis  of  the  legs 
and  genitals). 

The  prognosis  varies  greatly.  The  ordinary  non-suppurative  form 
of  the  face  and  scalp  usually  ends  in  recovery ;  that  of  the  trunk  is 
exhausting  and  not  infrequently  causes  death.  The  suppurative  form 
gives  rise  to  general  infection  and  metastases,  and  is  often  fatal. 
Alcoholics,  the  aged,  and  the  newborn  do  not  evince  effective  resist- 
ance. Insufficiency  of  the  heart's  action,  meningitis,  and  pneumonitis 
are  the  most  frequent  causes  of  death.  The  mortality,  based  on  10,000 
cases,  is  11  per  cent. 

The  recognition  of  erysipelas  is  based  on  its  acute  onset,  and  exten- 
sion of  redness  and  swelling  of  the  skin,  attended  with  chill,  high 
fever,  and  constitutional  symptoms.  It  is  not  readily  confused  with 
other  ailments. 

The  treatment  of  erysipelas,  of  itself,  is  as  widely  varied  as  it  is 
uniformly  unsatisfactory.  As  yet  no  agent  or  method  of  treatment 
has  succeeded  in  arresting  the  inflammation.  The  use  of  sera  has  not 
been  successful  (see  streptococci).  Efforts  at  mechanical  segregation 
by  means  of  the  cautery,  pressure  with  plasters,  or  the  application  of 
collodion,  etc.,  does  not  prevent  further  incursion  on  part  of  the  cocci ; 
and  injections  of  antiseptics  into  the  inflamed  areas  have  not  stayed 
their  progress.  Scarification  or  incision  followed  by  application  of 
chemical  antiseptic  solutions  (wet  dressings)  and  salves  has  proved 
ineffectual.  The  antiphlogistic  action  of  cold  (ice  bag)  increases  the 
danger  of  necrosis.  When  edema  is  marked,  and  threatens  to  cause 
pressure  necrosis,  acupuncture  is  indicated. 

Control  of  pain  and  the  prevention  of  complications  (secondary 
infection  and  mechanical  irritation)  should  be  aimed  at.  Moist  dress- 
ings and  soothing  ointments  relieve  pain.  As  the  former  nearly 
always  cause  dermatitis  and  thus  create  new  ports  of  entrance,  the 
dressing  should  be  coated  with  non-irritating  salves  —  zinc,  borated  or 
plain  vaselin  are  most  useful.  The  face  should  be  covered  with  a  mask 
thus  anointed  and  the  extremities  immobilized  in  splints. 

The  suppurative  forms  of  er^'sipelas  are  treated  along  the  lines  laid 
down  in  connection  with  pyogenic  infections  (p.  240). 


270  INFECTIONS  OF  WOUNDS 

Habitual  erysipelas  calls  for  the  removal  of  the  cause,  i.  e.,  abolition 
of  the  ports  of  entrance. 

The  constitutional  treatment  is  directed  toward  sustaining  the  heart 
and  increasing  general  resistance. 

Prophylaxis,  as  regards  wounds,  is  achieved  by  the  rigid  exercise  of 
measures  aimed  at  bacterial  destruction.     The  danger  op  contagion 

IN  ERYSIPELAS  IS  NO  GREATER  THAN  EXISTS  IN  ALL  STREPTOCOCCUS  INFEC- 
TIONS (Respinger*'),  and  therefore  does  not  call  for  the  exercise  of 
greater  care,  as  regards  isolation,  than  is  necessary  in  cases  of  pyogenic 
inflammation. 

The  therapeutic  effect  of  erysipelas  upon  malignant  neoplasma, 
gummata,  and  tuberculous  granulomata  was  first  reported  by  Busch^* 
(1866),  whose  observations  related  to  a  case  of  multiple  sarcomatosis 
of  the  skin.  Unfortunately  similar  results  have  not  been  obtained 
with  any  degree  of  certainty  (v.  Bruns^"'). 

Erysipeloid. —  At  times  the  skin  is  the  site  of  a  low  grade  of  infec- 
tion which  bears  some  resemblance  to  erysipelas,  and  is  variously 
designated  as  erysipelas  chronica,  erythema  migrans,  and  by  Rosen- 
bach^®  —  erj^sipeloid.  It  most  frequently  appears  in  connection  with 
slight  injuries  upon  the  fingers,  though  it  may  also  be  observed  upon 
the  nose,  cheek,  and  neck. 

Disturbances  of  a  general  nature  are  absent.  The  local  manifesta- 
tions consist  of  burning,  itching,  moderate  swelling,  and  the  appear- 
ance at  the  port  of  entrance  of  a  deep  red,  or  bluish  red  blush,  which 
gradually  lessens  in  intensity  as  it  merges  into  the  surrounding  skin. 
The  process  slowly  extends,  often  reaching  to  the  adjacent. fingers  — 
rarely  to  the  hand.  At  times,  an  obstinate  lymphangitis  of  the  arm 
occurs  (TaveP").  (The  cases  Tavel  bases  his  conclusions  on,  w^ere 
probably  not  erj^sipeloid,  but  mixed  infections  with  pj^ogenic  organ- 
isms—  Lexer^®). 

The  duration  of  erysipeloid  is  about  one  week,  though  obstinate 
cases  may  persist  for  from  three  to  four  weeks. 

The  causation  of  erysipeloid  would  seem  to  be  the  outcome  of  con- 
tact with  decomposing  animal  matter  and,  th(>refore,  it  occurs  most  fre- 
quently on  the  fingers  of  cooks,  or  persons  handling  such  commodities 
as  venison,  fish,  oysters,  cheese,  etc.  A  cladothrix  like  microorganism, 
isolated  in  pure  culture  by  Rosenbach^®  (1887),  and  inoculated  into 
the  skin,  was  followed  by  erysipeloid,  and,  therefore,  may  be  regarded 
as  the  excitant  of  the  disease.  This  was  later  (1904)  verified  by 
Ohlemann.^®     The  organism,  as  j^et  unclassified,  is  described  as  irregu- 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     271 

larly  round  and,  in  old  cultures,  giving  off  slender  thread-like 
prolongations. 

Recognition  of  the  disease  is  not  difficult.  The  absence  of  fever  and 
general  disturbances  readily  differentiates  it  from  erysipelas ;  and 
from  lymphangitis  reticularis,  which  also  attacks  the  fingers  but  does 
7iot  have  a  clearly  defined  line  of  demarcation.  An  inflammation  of 
the  fingers,  which  occurs  in  veterinarians  and  is  due  to  infection  with 
the  bacterial  excitants  of  ''swine  erysipelas,"  closely  resembles 
erysipeloid. 

The  treatment  of  erysipeloid  is  similar  to  that  of  erysipelas.  The 
affliction  is  likel}-  to  recur  unless  immobilization  is  maintained  until 
recovery  is  complete. 

B.     PYOGENIC  INFECTIONS  OF  MUCOUS  MEMBRANES 

As  the  bacterial  flora  of  mucous  membranes  consists  not  alone  of 
harmless  but  also  of  pyogenic  and  putrefactive  organisms,  it  is  quite 
understandable  that  inspiration  or  ingestion  of  additional  bacteria  is 
provocative  of  mixed  and  secondary  infections.  The  infectious  pro- 
cesses in  which  pyogenic  bacteria  are  the  dominant  causative  factor 
may  be  differentiated  from  those  resulting  from  the  invasion  of  putre- 
factive excitants,  despite  the  fact  that  these  coexist  and,  at  times,  the 
manifestations  of  either  one  seem  to  dominate  the  clinical  picture. 

Susceptitility  to  invasion  of  pyogenic  bacteria  on  the  part  of  mucous 
surfaces  is  the  outcome  of  the  virulence  of  the  aggressors,  and  the 
lessened  resistance  of  the  host.  When  these  conditions  obtain,  trau- 
matic or  pathological  solution  of  continuity  of  the  surface  of  the 
mucosa  (diphtheria,  gonorrhea,  ileus,  tuberculosis,  tA'phoid  ulcers, 
thrush,  carious  teeth,  and  ulcerating  alveolar  abscesses)  and  its 
peculiar  anatomical  arrangement  over  l;^Tnph  spaces  (tonsillar  crypts, 
etc.)  permits  of  the  free  entrance  of  infection.  A  lymphogenous 
inflammation,  results  from  local  extension.  A  hematogenous  inflam- 
mation occurs  as  a  part  of  a  sj'stemic  infection,  usuallj^  in  the  form  of 
an  embolic  abscess  in  the  gastric  or  intestinal  mucosa. 

In  chronic  poisoning  with  mercury,  phosphorus,  lead,  arsenic,  etc., 
attended  with  inflammatory  swelling  and  exfoliation  of  the  epithelium 
of  the  mucous  membrane  of  the  mouth,  the  thus  lessened  resistance  of 
the  tissues  favors  the  bacterial  invasion,  which  is  then  secondarily 
concerned  in  the  extension  of  the  necrotic  and  gangrenous  processes. 

The  chief  pyogenic  excitants  in  infectious  processes  of  mucous  mem- 
branes  are  staphylococci,  streptococci,  pneumococci,  gonococci,  hac- 


272  INFECTIONS  OF  WOUNDS 

terium  coli  communis,  and  pneumo-  and  influenza  hacilli.  Their  inva- 
sion is  followed  by  acute  superficial  or  deep  inflammations,  varying 
widely  in  the  character  of  their  local  and  general  disturbances. 

Superficial  inflammations  are  attended  with  serous,  purulent,  and 
fibrinous  exudation.  "When  hyperemia  and  edematous  swelling  accom- 
pany serous  and  purulent  catarrhal  inflammation,  hemorrhagic  areas 
appear  and,  w^hen  infiltration  is  extensive,  edema  glottidis  occurs. 
Virulent  processes  cause  exfoliation  of  epithelium  (desquamative 
catarrh),  abscess  formation  and  ulceration  w'hich  ultimate!}'  heals  by 
granulation.  The  lymphadenoid  organs  are  alwa.ys  enlarged  and  maj^ 
break  down  (tonsillar  abscess,  follicular  abscess  and  intestinal 
abscess). 

Fibrinous  deposits  are  the  result  of  coagulation  of  the  exudate  and 
are  deposited  on  the  exposed  submucous  connective  tissue  in  situations 
where  the  epithelium  has  undergone  ulcerative  destruction.  These 
j^ellowish  white  deposits  (interspersed  with  brown  areas,  due  to  small 
hemorrhages)  are  surrounded  by  a  dark  red  inflammatory  zone,  are 
more  or  less  adherent  to  the  underlying  tissue,  and  resemble  true 
diphtheria,  but  do  not  penetrate  as  deeply.  The  fibrinous  deposits, 
located  in  the  upper  air  passages,  complicating  measles,  scarlatina, 
pertussis,  pneumonitis,  tj^phoid  fever,  etc.,  are  the  result  of  strepto- 
coccus infection  and  are  called  diphtheroid,  in  contradistinction  to 
those  caused  by  diphtheria  bacilli.  Similar  deposits  occur  in  the 
urinary  bladder,  the  vagina  and  the  gut,  and  frequently,  as  the  out- 
come of  contamination  with  putrefactive  or  gangrene  producing  bac- 
teria, give  rise  to  ulceration.  The  small  round  areas  of  ulceration 
covered  with  fibrinous  exudate  that  are  found  in  the  mouth  are  called 
aphthae;  these  also  are  due  to  infection  with  pj'ogenic  bacteria. 

Deep  inflammations  of  the  mucosa,  following  wounds  or  the  entrance 
of  foreign  bodies,  or  those  resulting  from  extension  of  a  superficial 
infection,  lead  to  inflammatory  edema  and  phlegmon  of  the  subcuta- 
neous tissue.  The  superficial  mucosa  also  is  more  or  less  involved 
either  in  the  form  of  catarrhal  inflammation  or  of  tissue  necrosis. 

"When  outlets  of  bony  cavities  and  hollow  viscera,  such  as  the  gall 
bladder  and  the  appendix  vermiformis,  become  obstructed  by  inflam- 
matory swelling,  the  accumulated  exudate  (otitis  media,  empyema  of 
the  frontal,  maxillary  or  sphenoidal  sinuses,  empyema  of  the  gall 
bladder  and  appendix  vermiformis)  becomes  infected  with  putrefac- 
xive  bacteria  (as  the  result  of  extension),  causing  putrid  necrosis  of 
the  lining  mucous  membrane. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     273 

Though  erysipelas  of  mucous  membranes  occurs  as  an  active  super- 
ficial, and,  at  times,  submucous  phlegmonous  inflammation,  attended 
with  high  fever  and  grave  systemic  disturbances,  it  is  not  susceptible 
of  recognition  until  the  process  reaches  the  skin.  It  appears  in  the 
nose,  pharj'nx,  larynx,  and  female  genitals,  and  is  likely  to  become 
habitual  when  the  conditions  of  the  mucosa  in  these  regions  are  favor- 
able to  the  persistence  of  streptococcus  cultivation. 

The  outcome  of  mucous  membrane  infl.ammatioyis  is  variable. 
Catarrhal  inflammations  and  superficial  ulcerations  heal  without  scar- 
ring, the  exudate  being  absorbed  and  the  epithelium  regenerated. 
Deep  ulcers  leave  scars  of  greater  or  less  magnitude  in  accord  with 
the  extent  of  the  lesion.  Incomplete  restitution  to  the  normal  is  fol- 
lowed by  the  persistence  of  a  chronic  inflammatorij  process  that  leads 
to  glandular  hypertrophy  and  proliferation  of  lymphadenoid  tissue, 
or  to  atrophy  of  the  entire  mucous  membrane. 

The  surgical  importance  of  pyogenic  inflammations  of  mucous  mem- 
branes pertains  less  to  their  extension  from  the  upper  air  passages  to 
Ihe  lungs,  or  their  occurrence  in  the  stomach,  than  it  does  to  the 
purulent  pJilegynonous  form,  to  the  involvement  of  the  IjTnph  nodes, 
and  to  the  bacterial  invasion  of  the  body  generally. 

Phlegmon  of  mucous  membranes  is  attended  with  grave  menace.  The 
purulent  inflammation  of  glossitis  or  peri-odontitis  involving  the  floor 
of  the  mouth,  readily  extends  between  the  deep  muscles  of  the  neck, 
gains  access  to  the  mediastinum  and  causes  death.  When  situated 
beneath  the  mucosa  of  the  loiver  jaw  ajid  the  cheek,  the  phlegmon  may 
extend  to  the  base  of  the  skull  and  provoke  meningitis.  The  tonsillar 
crypts  are  often  the  seat  of  small  abscesses  that  involve  the  tonsil,  but 
they  may  also  give  rise  to  inflammation  of  the  peritonsillar  tissues  and 
soft  palate.  Phlegmon  of  the  pharynx  and  of  the  esophagus  also 
invades  the  mediastinum.  Abscessas  of  the  wall  of  the  gut,  and  sub- 
mucous phlegmons  of  the  pylorus,  at  times  rupture  and  cause  purulent 
peritonitis,  though  this  occurs  most  frequently  in  connection  Math 
inflammation  of  the  appendix  verniiformis.  Abscesses  in  the  urinary 
bladder  rupture  into  the  perivesicular  tissue,  and  peri-urethral 
phlegmon  follows  rupture  of  infective  foci  of  the  urethra  (ulceration 
and  injury  from  catheterization).  In  the  neighborhood  of  the  rectum, 
phlegmonous  periproctitis  leads  to  the  formation  of  an  ischiorectal 
abscess  with  its  frequent  sequential  fistula  ani  or  recti.  Where  the 
submucous  connective  tissue  is  in  contact  with  bone,  a  phlegmonous 


274  INFECTIONS  OF  WOUNDS 

inflammation  is  likely  to  give  rise  to  suppurative  periostitis,  osteomye- 
litis, and  necrosis. 

All  inflammations  of  mucous  membranes  extend  to  the  contiguous 
lymph,  glands,  a  fact  frequently  demonstrated  in  the  lymph  nodes  of 
the  neck  (in  angina).  The  lymphatic  swelling  disappears  when  the 
primary  process  heals,  but  persists  w^hen  the  latter  frequently  recurs, 
or  when  the  pharynx  is  maintained  in  a  constant  state  of  irritation  by 
the  presence  of  constant  lymphadenoid  hyperplasia.  "When  lymph- 
adenitis complicates  virulent  suppurative  phlegmonous  inflammation, 
it  is  likely  to  be  attended  with  abscess  formation. 

The  absovption  of  virulent  excitants  from  both  superficial  and  deep 
suppurative  inflammations  of  mucous  membranes  causes  the  develop- 
ment of  metastatic  foci  or  general  infection.  This  is  shown  in  cases 
of  hematogenous  gd^iorrheal  arthritis.  The  severest  and  most  fre- 
quently fatal  systemic  infections  occur  in  connection  with  virulent 
catarrhal,  phlegmonous,  and  putrid  inflammations  of  the  mucous  mem- 
branes, due  to  streptococci.  In  some  instances,  bacteremia  follows 
bacillus  coli  infection  of  the  intestinal  mucosa.  A  causative  relation- 
ship seems  to  be  established  between  acute  angina  (due  to  streptococci, 
staphylococci,  pneumococci,  etc.,  or  to  inflammations  of  the  accessory 
sinuses  of  the  nose)  and  pyo-arthrosis,  abscesses  in  muscles,  metastatic 
phlegmon,  and  osteomj^elitis. 

In  the  treatment  of  pyogenic  inflammations  of  mucous  memhranes, 
the  employment  of  measures  tending  to  favor  the  absorption  of  the 
excitants  —  such  as  the  frequent  painting  of  the  pharynx,  syringing 
of  the  nasal  passages,  mouth,  urethra,  etc.,  and,  most  of  all,  wiping, 
avulsion  or  curetting  of  the  fibrinous  deposits,  should  be  avoided. 

The  application  of  disinfecting  agents  does  not  lessen  the  viability 
of  the  bacteria  embedded  in  the  membrane,  nor  do  they  reach  those 
nesting  in  its  folds  and  niches;  on  the  contrary,  chemical  bactericides 
irritate  the  surface  of  the  mucosa,  cause  the  destruction  of  epithelium, 
and  make  available  to  invading  bacteria  additional  ports  of  entrance. 
This  is  frequently  observed  in  cases  of  gonorrhea  in  which  the  highly 
inflamed  urethra  is  mechanically  injured  by  the  forcible  injection  of 
chemical  agents.  To  this  may  be  added,  that  the  repeated  use  in  the 
oral  cavity  of  chemical  disinfectants  (kali  chlorate),  with  consequent 
deglutition,  often  leads  to  objectionable  occurrences. 

Efforts  at  relief  should  be  directed  toward  the  mechanical  removal 
of  the  excitants  contained  in  the  secretions  of  the  mucous  surfaces, 
and  the  lessening  of  their  multiplication.     This  is  attained  by  frequent 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     275 

lavage  (the  method  varymg  iu  accord  with  the  locahty  uuder  consid- 
eration, i.  e.,  gargling,  rinsing,  gentle  irrigation,  etc.)  with  lukewarm 
sterile  water,  physiological  salt  solution,  or  dilute  antiseptic  (kali 
permanganate  0.5-1.0:2000,  boric  acid  0.5:1000,  sublimate  0.5-1.0: 
5000,  aluminum  acetate,  menthol,  thymol,  salicylic  acid,  etc.).  Per- 
haps the  use  of  3  per  cent  hydrogen  peroxid  mixed  with  physiological 
salt  solution  (especially  in  the  mouth),  as  the  outcome  of  its  deodoriz- 
ing effect  and  because  of  the  gentle  action  of  its  "foam"  in  mechan- 
ically cleansing  the  infected  area,  will  give  the  most  satisfactory 
results. 

Prophylaxis  is  conserved  by  attention  to  the  hygiene  of  the  mouth 
which  is  the  most  frequent  site  of  infection,  the  contiguous  ca^aties 
being  usually  involved  by  extension.  For  this  purpose,  reliance 
should  be  placed,  less  upon  the  use  of  antiseptic  tooth  pastes  and 
mouth  washes,  than  upon  the  mechanical  cleansing  of  the  teeth  and 
mouth  with  the  brush  and  by  lavage  (v.  Mikulicz  and  Kiimmel,^° 
Feder-^). 

Phlegmon  of  mucous  membrances  is  to  be  treated  on  general  prin- 
ciples. Complications  are  to  be  taken  care  of  in  accord  with  the 
special  indications.  Obstinate  ulceration  should  be  loosely  tamponed 
with  iodoform  gauze  or,  when  accessible,  iodoform  glycerin  may  be 
frequently  applied  (v.  Mikulicz-").  Necrotic  or  gangrenous  areas 
may  be  "dabbed"  (not  rubbed)  with  alcohol,  spirits  of  camphor, 
acids,  or  touched  lightly  with  the  actual  cautery. 

In  cases  of  severe  infection,  the  general  nutrition  should  be  taken 
care  of,  with  the  view  of  maintaining  the  resistance  of  the  infected 
membrane. 

Chronic  inflammatory  areas  should  be  frequently  lavaged  with  salt 
solutions.  Alkaline  mineral  waters  mixed  with  milk  ma}^  be  swallowed 
at  short  intervals.  The  local  application  of  1  per  cent  tannin  and 
tdum  solutions;  2-10  per  cent  argenti  nitras  solution  and  iodo- 
glycerin,  by  means  of  cotton  pledgets,  are  of  value.  Hj-pertrophic 
areas  may  be  subjected  to  the  application  of  concentrated  solutions  of 
silver,  tannin,  etc.  H^-pertrophied  pharjTigeal  tonsils  and  enlarged 
lingual  tonsils  should  be  removed,  as  they  furnish  the  nidus  from 
which  frequent  infectious  excursions  take  place. 


276  INFECTIONS  OF  WOUNDS 

C.     PYOGENIC  INFECTIONS  OF  LYMPH  VESSELS  AND  LYMPHATIC 

GLANDS 

The  absorption  of  bacteria  and  their  toxins  from  the  fluids  surround- 
ing pyogenic  processes  is  the  outcome  of  the  capillarity  of  the  lymph 
stream  which  causes  them  to  enter,  successively,  the  lymphatic  spaces, 
capillaries,  vessels,  and  glands,  though  the  bacteria  in  inflammatory 
areas  also  gain  access  to  the  lymph  stream  by  penetrating  the  delicate 
walls  of  the  lymph  channels.  During  this  time  the  lymph  exercises 
its  available  bactericidal  action,  and  the  remaining  excitants  are  col- 
lected within  the  glands  and  destroyed  there  without  the  occurrence 
of  symptoms,  unless  the  bacteria  are  present  in  numbers  too  great  or 
are  too  virulent  to  be  destroyed  by  the  bactericides,  or  their  endotoxins 
give  rise  to  inflammatory  reaction.  When  the  bacteria  are  not 
destroyed,  their  appearance  in  the  connective  tissue  spaces  and  in  the 
glands  of  inflammatory  areas  denotes  the  beginning  of  the  combat 
between  the  pathogenesis  of  the  invaders  and  the  resistance  of  the 
host.  Often  the  combat  is  violent  and  extends  far  out  into  the  sur- 
rounding TISSUES,  but  ONLY  WHEN  THE  BACTERICIDAL  POWDER  OF  THE 
LYMPH  GLANDS  WANES  AND  THE  INVASION  OF  THE  LARGER  LYMPH  VESSELS 

IS  NO  LONGER  OBVIATED  docs  the  blood  Stream  become  contaminated  and 
bacteriemia  established  (p.  331). 

The  early  occurrence  of  lymph  vessel  and  gland  inflammation  fol- 
lowing injury  indicates  aggression  by  virulent  excitants.  This 
explains  the  rapid  development  of  lymphatic  inflammation  in  infec- 
tions contracted  at  autopsies  and  at  surgical  operations,  as  especially 
virulent  bacteria  are  derived  from  these  sources. 

The  most  frequent  cause  of  acute  lumphangitis  and  lymphadenitis 
(rarely  of  the  chronic  forms)  is  infection  with  the  various  kinds  of 
pyogenic  bacteria,  prominent  among  which  are  staphylo-  and  strepto- 
cocci (E.  Fischer-^).  These  inflammations  originate  in  severely 
infected  wounds,  after  injury  to  lightl,y  infected  wounds,  in  granulat- 
ing and  ulcerating  surfaces,  in  superficial  and  deep  inflammatory 
foci,  and  in  infected  mucous  membranes. 

Acute  Lymphangitis. —  The  local  manifestations  of  acute  lymph- 
angitis are  most  clearly  defined  in  connection  with  infection  of  the 
cutaneous  and  suhcutaneous  vessels.  They  appear  most  frequently 
upon  the  extremities,  chiefly  the  upper,  the  fingers  of  which  possess  a 
multitude  of  ports  of  entrance  favorable  to  the  invasion  of  bacteria. 
The  skin  surrounding  a  slight  wound  in  the  zone  where  the  lymph 
vessels  originate  in  the  finger  tips,  or  a  small  ulcer  of  the  forearm, 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      277 

suddenly  —  without  any  assignable  cause,  develops  an  itching  or  burn- 
ing area  of  redness  which  gradually  merges  into  the  healthy  skin  and 
extends  in  the  direction  of  the  lymph  stream.  In  accord  with  the  fine 
net  like  ramifications  of  the  lymphatics,  the  redness  appears  as  a  sym- 
metrical blush,  or  is  irregularly  spotted.  In  a  few  hours  a  varj'ing 
number  of  red  streaks  extend  from  their  point  of  origin  near  the 
wound,  upward  along  the  arm,  unite  into  a  single  streak  near  the 
axilla,  and  end  in  a  swollen  gland  in  this  region.  From  the  foot, 
streaks  extend  into  the  hollow  of  the  knee  or  disappear  in  the  anterior 
portion  of  the  thigh,  as  the  lymph  vessels  follow  the  course  of  the  long 
saphenous  vein.  In  a  few  days  the  red  streaks  deepen  in  color,  and 
upon  palpation  may  be  recognized  as  hard,  tend(*r  cords.  The  skin 
of  the  entire  limb  becomes  moderately  swollen  and  tense. 

Inflammation  of  deep  lymph  vessels  is  attended  with  dull,  heavy, 
rapidly  increasing  pain  and  swelling  of  lymph  glands.  It  is  fre- 
quently secondary  to  infection  of  the  superficial  lymphatics,  but  may 
occur  alone. 

The  course  of  the  disease  is  varyingly  mild  or  severe  in  accord  with 
the  character  of  the  infection  and  the  complications. 

Superficial  lytnphangitis  may  disappear  in  one  or  two  days,  in  which 
event  the  hyperemia  and  the  serous  infiltration  of  the  lymph  vessels 
and  their  vicinity  is  followed  by  a  moderate  degree  of  epithelial  exfoli- 
ation. In  this  simple  form  of  lymphangitis,  new  streaks  of  redness 
occasionall}^  appear  as  the  older  ones  become  pallid.  In  other  cases 
the  streaks  —  at  the  end  of  two  or  three  days  —  become  hard  cords, 
at  times  as  thick  as  the  little  finger.  This  form  of  l^'mphangitis  is 
attended  with  severe  h3'peremia ;  the  deposit  of  exudate  in  the  walls 
of  the  lymph  vessels  and  the  tissues  surrounding  them ;  with  swelling 
and  epithelial  exfoliation;  and  as  the  result  of  coagulation  of  the 
lymph,  thrombi  are  formed  (at  first  at  the  site  of  the  valves).  These 
thrombi  contain  lymphoc>i:es,  leukoc}i:es,  endothelial  cells,  and  bac- 
teria; when  increased  to  an  extent  sutficient  to  obliterate  the  lumen  of 
the  larger  vessels,  stasis  of  the  lymph  flow  takes  place  {thronibo- 
lymphangitis) .  Recession  is  slow  (one  to  two  weeks);  the  streaks 
become  brown,  then  yellow,  and  the  edematous  swelling  of  the  skin 
and  hardening  of  the  weals  gradually  disappears;  the  thrombi  are 
slowly  dissolved,  the  lumen  reestablished,  new  endothelium  is  pro- 
liferated and  the  exudate  is  absorbed. 

The  suppurative  form  is  severe.  When  the  thrombi  undergo  sup- 
purative degeneration,  the  walls  of  the  vessels  become  necrotic,  and 


278  INFECTIONS  OF  WOUNDS 

pyogenic  inflammation  extends  into  the  surrounding  tissues,  giving 
rise  to  the  formation  of  subcutaneous  abscesses.  These  hjmpJiangitic 
ahscesses,  which  take  on  the  form  of  subcutaneous  phlegmon,  occur  at 
the  end  of  the  first,  or  during  the  second  week  of  the  process  and  often 
develop  in  sequence  over  a  long  period  of  time. 

The  deep  lymph  channels  are  attacked  in  a  similar  manner,  but  only 
the  purulent  forms  become  manifest,  and  then  not  until  the  pus 
extends  to  and  invades  the  skin. 

The  beginning  and  extension  of  acute  lymphangitis  is  always 
attended  with  fever,  chill,  and  the  constitutional  manifestations  com- 
mon to  acute  infectious  diseases.  The  fever  falls  with  each  recession 
and  rises  with  each  extension  of  the  inflammation. 

The  complications  are  chiefly  abscess,  phlegmon,  and  suppurative 
lymphadenitis.  Phlehitis  of  the  superficial  and  deep  veins  develops 
from  migration,  through  their  thin  walls,  of  the  pyogenic  process, 
causing  thrombosis.  Metastatic  foci,  especially  in  the  lung,  are  more 
likely  to  follow  phlebitis  than  lymphadenitis,  though  lymphangitic 
emboli  may  circumvent  the  glands  (by  anastomotic  vessels)  and  gain 
access  to  the  right  heart  (NotzeP^),  In  severe  general  infection, 
acute  lymphangitis  frequently  forms  the  first  link  in  the  chain  of 
varied  manifestations  common  to  this  condition.  Erysipelas  is  also, 
at  times,  preceded  by  the  appearance  of  the  red  streaks  characteristic 
of  this  process. 

The  severity  of  the  inflammation  depends  upon  the  virulence  of  the 
excitants  and  the  resista^ice  of  the  host.  Infections  contracted  at 
autopsies  or  during  operations  for  the  relief  of  pyogenic  inflamma- 
tions have  a  tendency  to  assume  menacing  characteristics.  In  alco- 
holics, diabetics,  and  debilitated  persons,  the  affliction  is  also  likely  to 
follow  a  stormy  course.  In  many  instances  the  infection  is  obstinately 
maintained.  Thrombosis  recedes  very  slowly  and  at  intervals,  gives 
rise  to  the  development  of  additional  more  or  less  remotely  located 
infectious  areas  (embolic). 

The  recognition  of  acute  lymphangitis  is  not  fraught  with  difficulty. 
At  the  port  of  entrance  the  initial  inflammation  may  be  confused  with 
a  receding  erysipelas  or  erysipeloid,  when  the  lines  of  demarcation  of 
the  latter  have  faded.  The  superficial  cord-like  thickening  of  lymph- 
angitis may  simulate  phlebitis,  and  the  deeply  located  processes  may 
be  mistaken  for  inflammations  originating  in  the  bones,  especially  in 
the  arm,  in  the  popliteal  space,  and  in  Scarpa's  triangle. 

The  treatment  consists  of  absolute  rest,  as  muscular  movements 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES'     279 

accelerate  the  flow  of  lymph.  The  infected  part  should  be  elevated 
and  immohilized  by  the  application  of  the  protective  dressing  held  in 
place  by  splints,  as  long  as  the  streaks  are  discernible  or  palpable. 
The  use  of  inunctions  and  massage  should  be  avoided,  as  they  favor 
propulsion  of  the  excitants  and  emboli  into  the  circulation.  Nosske^* 
advises  the  emploj^ment  of  transverse  incisions  down  to  the  fascia, 
close  to  the  trunk.  By  this  means  the  lymph  channels  are  quickly 
emptied  and  the  duration  of  the  process  shortened.  Pain  is  lessened 
by  the  application  of  dressings  covered  with  salve.  Abscesses  should 
be  freely  incised.  If  thrombosis  is  present,  exsangnination  prelimi- 
nary to  incision  should  be  avoided. 

Chronic  Lymphangitis. —  The  chronic  form  of  lymphangitis  follows 
frequently  repeated  acute  attacks,  or  may  be  due  to  the  persistent 
absorption  of  infectious  substances  from  eczema  or  ulceration  of  the 
skin.  The  constantly  inflamed  l^-mph  vessels  are  ultimately  obstructed 
or  obliterated  by  connective  tissue  hyperplasia  and  may  fijially  pro- 
voke acquired  elephantiasis  or  pachyderma.  Treatment  is  directed 
toward  removal  of  the  cause,  and  promotion  of  absorption  of  the 
products  of  infection  with  pressure  and  massage. 

Lymphadenitis. —  The  lymph  glands  are  mechanically,  and  by  the 
action  of  the  phagocytes,  concerned  in  the  removal  from  the  lymph 
stream,  of  dust  particles,  coloring  matter,  the  products  of  cell  degen- 
eration contained  in, exudates  (pigment  of  red  corpuscles,  etc.),  and 
bacteria.  All  but  the  last  are  confined  for  a  long  time  in  the  proto- 
plasm of  the  endothelial  cells  lining  the  lymph  vessels  and  cause  either 
hypertrophy  or  atrophy  of  tissue ;  the  bacteria,  when  present  in  large 
numbers,  immediately  onidtiply  and  provoke  within  the  gland  the 
phenomena  common  to  inflammation,  with  its  variations  in  form,  not 
infrequently  ending  in  suppuration  and  abscess  formation. 

The  .lymph  nodes  contiguous  to  inflammatory  foci  are  always 
involved,  but  the  number  of  a  given  group  that  break  down  varies  in 
accord  with  the  virulence  of  the  primary  process.  The  conducting 
l^'mph  vessels  may  escape  infection  entirely  or  may  become  severely 
involved. 

Infections  of  the  glands  are  usually  conveyed  through  the  lymph 
vessels,  but  may  be  hematogenous  in  origin  and  then  occur  as  part  of 
a  general  infectious  disease,  such  as  pest,  measles,  scarlatina,  etc. 

The  course  of  the  inflammation  takes  on  the  character  of  an  acute  or 
chronic  lymphadenitis,  and  involves  most  frequently  the  glands  in  the 
neck,  the  axilla,  and  the  groin. 


280     •  INFECTIONS  OF  WOUNDS 

The  simple  form  (lymphadenitis  simplex)  attends  mild  peripheral 
inflammations  or  more  severe  ones  that  have  not  been  promptly  treated 
(abscesses  freely  incised).  Usually  one  gland  enlarges  to  the  size 
of  a  walnut  and  is  surrounded  by  several  smaller  ones.  In  the  absence 
of  peri-adenitis  the  nodes  are  movable,  as  is  the  skin  over  them.  When 
the  provocative  inflammation  heals,  the  enlargement  of  the  glands 
subsides,  and  complete  restitution  to  the  normal  takes  place.  In  the 
chronic  forms  of  inflammation  the  glands  become  enlarged  from 
hyperplasia. 

When  sectioned,  the  hyperemic  gland  is  found  filled  with  a  grayish 
red  infiltrate,  consisting  of  blood  and  serous  or  fibrinous  exudate, 
which  distends  its  capsule.  The  exudate  contains  a  large  number  of 
leukocytes  and  endothelial  cells  derived  from  the  glandular  sinuses. 
Recession  is  attended  with  gradual  absorption  of  the  cellular  elements 
and  the  exudate,  the  disappearance  of  the  hyperemia,  and  regeneration 
of  the  endothelial  cells. 

The  suppurative  form  (lymphadenitis  purulenta)  is  attended  with 
peri-adenitis  and  presents  a  twofold  picture. 

First:  That  (called  seropurulent)  associated  with  streptococcus 
infections,  attended  with  grave  systemic  disturbances  and  extension 
in  the  form  of  subcutaneous  and  intermuscular  phlegmon  (neck, 
thoracic  muscles  and  abdominal  wall),  and  manifested  by  swollen 
groups  of  glands  which,  in  a  few  days,  are  surrounded  by  inflamma- 
tory edema.  The  slightly  reddened  hard  skin  is  usually  adherent  to 
the  underlying  mass  which  does  not  fluctuate. 

When  exposed  by  operation,  this  mass  is  found  to  consist  of  enlarged 
glands  imbedded  in  edematous  peri-adenitis.  These  glands,  when  sec- 
tioned, present  a  grayish  red  mottled  surface,  studded  with  small 
purulent  and  hemorrhagic  areas  surrounded  by  a  dark  red  hj^peremic 
parenchyma.  The  surrounding  edematous  tissues  are  also  flecked 
with  small  pus  areas  not  unlike  those  common  to  seropurulent 
phlegmon.  The  microscope  reveals  the  lymph  channels  filled  or  dis- 
tended with  fibrinous  deposits  which,  together  with  the  contiguous 
tissues,  are  liberally  infiltrated  Math  leukocytes,  red  blood  corpuscles, 
and  myriads  of  bacteria.  If  progressive  phlegmonous  inflammation 
has  already  developed  the  glands  are  often  found  necrotic. 

Second:  That  (called  the  pyogenic  form)  which,  in  sequence  to 
the  seropurulent  form,  suppurates  or,  as  is  more  usual,  begins  mildly 
isuhacute),  but  is  soon  followed  by  abscess  formation.  When  the 
abscess  ruptures  subcutaneously,  a  circumscribed  phlegmonous  inflam- 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     281 

mation  (peri-adenitis  puriilenta)  develops,  wliicli,  however,  does  not 
progress.  The  glands,  at  first  hard  and  movable,  gradually  become 
attached  to  the  surrounding  tissues  and  slightly  reddened  skin,  soon 
soften,  fluctuate  and  make  ready  to  rupture.  This  is  due  to  the 
coalescence  of  several  glands,  the  contiguous  capsules  of  which  rup- 
ture, forming  lymphadenitic  abscesses.  The  contents  of  these 
abscesses  are  not  infrequently  spontaneously  discharged  upon  the 
surface  of  the  body.  Constitutional  symptoms  attend  the  primary 
inflammation  and  soon  subside,  but  recur  in  the  event  of  development 
of  phlegmon  due  to  subcutaneous  rupture  of  the  abscess. 

Lymphangitis  inguinalis  (bubo),  which  belongs  to  the  form  just 
described,  originates  in  connection  with  ulcus  molle.  The  pus  con- 
tains the  same  bacterium  found  at  the  site  of  the  chancroid. 

The  chief  excitants  responsible  for  the  lymphadenitis  are  the  same 
as  those  that  cause  Ij^mphangitis.  Gonococci  are  found  in  bubo  com- 
plicating gonorrheal  urethritis.  Mixed  infections  are  common.  When 
due  to  pittref active  bacteria,  the  clinical  picture  —  except  for  the 
presence  of  gangrene,  simulates  that  presented  in  the  sercfibrinous 
form. 

The  presence  of  bacteria  in  the  glands  cannot  alwaj'S  be  demon- 
strated. Early  in  the  course  of  acute  extending  processes,  the  bacteria 
are  not  difficult  to  find.  However,  in  l^-mph  gland  abscesses  of  longer 
standing,  the  excitants  are  markedly  reduced  in  number,  or  are  dead. 
In  the  simple  form  of  gland  inflammation  they  succumb  earl}^ 

The  complications  of  lymphadenitis  are:  Abscess  formation;  and 
the  development  of  phlegmonous  inflammation.  In  glands  located 
immediately  contiguous  to  large  veins  (jugular,  femoral,  saphenous, 
axillary,  etc.),  thrombophlebitis  may  occur,  which,  of  couri-e,  encom- 
passes the  danger  of  embolic  abscesses  of  the  lung.  As  the  small 
veins  in  the  capsules  of  inflamed  glands  and  the  lumen  of  infected 
lymph  vessels  contain  thrombi  fertilized  by  bacteria,  this  also  happens 
when  the  lesion  is  subjected  to  trauma  (massage,  etc.).  Systemic 
infection  is  also  a  not  infrequent  complication  of  13'mphadenitis.  The 
progressive  inflammatory  processes  that  follow  infection  of  wounds 
are  not  always  restrained  by  the  defensive  activities  of  the  lymphatic 
sj'stem,  and,  when  these  are  exhausted,  systemic  infection  follows. 

The  recognition  of  acute  lymphadenitis  is  not  ditficult.  The  loca- 
tion of  the  process  is  usuallj^  indication  enough,  in  this  connection. 

The  treatment  pertains  to  that  of  the  primarj^  causative  factor. 


282  INFECTIONS  OF  WOUNDS 

The  affected  gland  should  be  protected  from  both  active  and  passive 
trauma. 

Immobilization  in  splints  and  elevation  of  the  affected  part  is  often 
followed  by  recession  of  the  process,  especially  in  the  simple  forms  of 
lymphadenitis.  All  motion  and  mechanical  irritation  (inunctions, 
massage,  pressure  with  sand  bags,  lead  plates,  etc.)  should  be  avoided, 
as  they  tend  to  promote  dissemination  of  the  excitants,  and  propulsion 
of  the  fibrinous  exudates  into  the  blood  stream.  Mild  counter  irritants, 
like  mercurial  salve,  tincture  of  iodine,  etc.,  mask  the  clinical  picture 
and  afford  less  relief  than  is  accomplished  by  complete  rest.  In  the 
simple  forms  of  lymphadenitis  (especially  in  the  neck),  wet  com- 
presses relieve  pain,  but  when  suppuration  occurs,  these,  together  with 
poultices,  should  be  avoided. 

In  the  purulent  forms,  the  glands  are  (according  to  the  character 
of  the  process)  either  extirpated,  incised,  or  aspirated.  Severe  sero- 
purulent  lymphadenitis  should  be  freely  exposed  and  removed. 
Incision  and  drainage  does  not  serve  the  purpose.  The  residual 
glandular  tissue  develops  renewed  phlegmonous  extension.  The 
lymphatic  circulation  is  reestablished  despite  the  removal  of  all  the 
glands  of  an  affected  region ;  per  contra,  when  left  to  the  destructive 
action  of  pyogenic  infection,  lymph  stasis  occurs. 

When  abscesses  form,  simple  incision  suffices,  as  the  broken  down 
glandular  tissue  does  not  provoke  extension-  of  inflammation,  and  is 
discharged  through  the  wound.  When  the  abscess  is  restricted  to  the 
gland  structure,  aspiration,  or  simple  puncture,  may  be  all  that  is 
necessary.  Residual  portions  of  the  gland  may  be  caused  to  undergo 
liquefaction  and  subsequent  absorption,  or  be  removed  by  aspiration, 
or  b}'  repeated  injections  of  small  portions  of  1  per  cent  benzomercury 
or  physiological  salt  solution  (Thorn-'^).  The  injection  treatment  is 
useful  in  venereal  bubo.  It  must,  however,  be  used  only  when  pus  is 
present ;  before  this,  the  increased  tension  it  produces  may  cause  the 
same  damage  that  obtains  in  connection  wnth  other  mechanical 
irritation. 

Chronic  lymphadenitis  (simplex)  is  caused  by  the  frequently 
repeated  infection  of  contiguous  surfaces,  or  results  from  the  per- 
sistent absorption  of  inflammatory  products  originating  in  chronically 
irritated  mucous  membranes,  eczematous  patches,  or  ulcers  of  the  skin. 

The  glands  thus  affected  are  either  large  and  soft,  due  to  simple 
hypertrophy;  or,  as  the  outcome  of  connective  tissue  proliferation  of 
the  capsule,  they  shrink  and  become  hard  {fibrous  hyperplasia). 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     283 

Hypertrophied  glands  in  the  neck  are  due  to  eczema  of  the  scalp, 
rliagades  of  the  nose  and  lips,  or  catarrh  of  the  mucous  membranes, 
and  may  present  the  clinical  picture  of,  so-called,  scrofula  (pj^ogenic 
scrofula),  or  thej^  may  become  tuberculous. 

Shrunken  glands  must  be  differentiated  from  tuberculosis.  In  the 
region  of  carcinoma,  the  glands  are  hard  and  nodular. 

The  treatment  of  chronic  IjTnphadenitis  must  be  directed  toward  the 
removal  of  the  cause. 

D.    PYOGENIC  INFECTIONS  OF  BLOOD  VESSELS 

Pyogenic  inflammations  of  the  walls  of  arteries  and  veins  are  the 
result  of  extension  from  contiguous  lesions  or  are  hematogenous  in 
origm,  and  therefore  appear  in  connection  with  local  and  general 
purulent  processes. 

Arteritis. —  Arteritis  purulenta  occurs  less  frequently  than  phlebitis 
because  of  the  greater  thickness  of  the  walls  of  the  arteries,  and 
begins  as  a  peri-  or  endarteritis,  according  to  whether  the  excitants 
attack  the  w^alls  of  the  vessels  from  without  or  from  within.  When 
the  wall  of  a  large  artery  is  persistently  bathed  in  the  purulent  exudate 
of  an  acute  or  chronic  suppurative  process,  it  becomes  separated  from 
its  surrounding  tissues,  and  peri-arteriiis  develops.  This,  not  infre- 
quentl}',  occurs  in  the  neck  and  groin,  where  suppurative  processes  are 
often  maintained  for  a  long  time.  Trauma  plays  a  causative  role 
when  arteries  are  deligated  with  fertilized  ligatures,  or  are  contused 
by  crushing  injuries,  or  when  drainage  material  is  left  in  prolonged 
contact  wdtli  a  blood  vessel.  Endarteritis  follows  the  breaking  down 
of  a  pyogenic  arterial  thrombus,  or  w^hen  an  infectious  embolus  lodges 
in  the  lumen  of  a  vessel  {throniho-arteritis  purulenia) .  In  general 
infections  (bacteremia),  the  excitants  maj'  gain  access  to  the  w^all  of 
the  vessel  through  the  vasa  vasorum  and  provoke  thrombosis,  necrosis, 
and  gangrene  (influenza,  typhoid  fever,  etc.). 

Moderate  inflammations  provoke  cellular  infiltration  and  thickening 
of  one  or  more  coats  of  the  artery.  Involvement  of  the  inner  coat  gives 
rise  to  proliferative  obliteration  of  the  lumen  (endarteritis  produc- 
tiva)  ;  those  of  greater  intensity  go  on  to  pijogenic  destruction  of  the 
arterial  wall.  In  the  smaller  vessels,  obturating  thromhi  obviate  the 
occurrence  of  bleeding,  and  lead  to  destructive  suppuration.  In  the 
large  vessels,  the  thrombi  also  break  down,  the  walls  of  the  vessels  are 
perforated  (especially  in  large  gangrenous  areas),  and  more  or  less 
menacing  hemorrhage  is  the  result.     When  the  ulcerated  vessel  per- 


284  INFECTIONS  OF  WOUNDS 

forates  into  au  abscess  cavity,  a  false  aneurism  or  'pulsating  hematoma 
occurs.  At  times  the  wall  of  the  vessel  slowly  dilates  at  the  site  of  the 
infection  before  it  ruptures,  forming  a  true  aneurism.  Often,  just 
'before  rupture  of  the. true  aneurism,  the  remaining  coat  of  the  artery 
(inner  or  outer  according  to  the  location  of  the  original  focus)  is 
"ballooned  out"  by  the  blood  pressure,  forming  a,  so-called,  sponta- 
neous aneurism.  Aneurisms  of  this  sort  caused  b}'  the  deposit  of 
infectious  emboli  are  called  emholo-mycoiic  aneurisms. 

To  prevent  arteritis  of  large  vessels,  incision  and  drainage  of  deep 
abscesses  and  phlegmon  encompassing  them  should  be  carefully  exe- 
cuted, and  injury  to  the  vessel  walls  avoided.  In  suppurating  areas, 
arterial  hemostasis  by  ligature  should  be  supplemented  with  tampon 
pressure  (for  one  week),  with  the  view  of  lessening  the  impact  of 
blood  provoked  by  each  ventricular  systole. 

Imminent  rupture  of  an  infected  artery  is,  at  times,  indicated  by 
the  development  of  an  emholic  aneurism.  Sudden  pain,  and  the 
appearance  of  a  pulsating  SM^elling,  should  arouse  suspicion  in  this 
connection.  Distal  double  ligature  of  the  affected  artery  should  be 
promptly  executed. 

Phlebitis. —  Phlehitis  purulenta  frequently  begins  as  a  periphlebitis 
in  conjunction  with  inflammation  of  the  hTupli  vessels  enmeshing  or 
accompanying  a  large  vein,  or  it  is  due  to  the  extension  of  contiguous 
pyogenic  inflammation  to  its  wall.  When  the  inflammation  arises 
from  within  the  lumen  of  the  vessel,  the  thrombus  is  hematogenous  in 
origin.  As  the  slowing  of  the  circulation  and  the  formation  of  thrombi 
in  the  small  veins  of  an  infectious  focus  favor  the  migration  of  excit- 
ants, phlebitis  is  a  frequent  occurrence. 

Moderate  wiflammation  of  subcutaneous  veins,  not  attended  with 
suppuration,  is  characterized  by  a  hard,  cord  like  thickening  (the  size 
of  the  little  finger)  of  the  vessels,  and  redness  of  the  overlying  skin 
resembling  thrombolymphangitis.  Becession  of  the  process  is  followed 
by  organization  of  the  clot,  and  its  canalization,  or  by  permanent 
obliteration  of  the  lumen  of  the  vein.  Frequently  repeated  phlebitis 
(in  connection  with  ulcer  of  the  leg)  also  causes  thickening  of  the  walls 
of  the  vessels,  and  narrowing  or  obliteration  of  their  lumen  (phlebitis 
chronicohyperplastica).  Insular  deposits  of  lime  salts  in  thrombo- 
phlebitis cause  the  development  of  phleholiths. 

Intense  inflammations  are  attended  with  pyogenic  infiltration  of  the 
veins  and  the  tissues  surroundmg  them.  Incision  reveals  the  yellow, 
thickened,  rigidly  gaping  vessel  w^all  which,  together  with  the  contigu- 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      285 

ous  tissues,  is  heavily  infiltrated  with  fibrinopurulent  exudate. 
Pyogenic  inflammations  of  veins  ake  always  attended  by  the 
FORMATION  OF  THROMBI.  The  deposit  of  fibrin  is  the  outcome  of  the 
action  of  bacterial  poisons  that  enter  the  vein  through  its  intima 
(Talke-"),  and  of  the  inflammatory  exudate  originating  in  the  vasa 
vasarum  (thrombophlebitis  puruleuta).  Per  contra,  phlebitis  always 
follows  pyogenic  disintegration  of  a  thrombus. 

Disintegration  of  a  thrombus,  and  pyogenic  degeneration  of  the 
wall  of  the  vein,  is  followed  by  the  entrance  of  pus  into  the  surround- 
ing tissue,  where  it  either  causes  abscess  formation,  or  is  succeeded  by 
extension  of  the  preexisting  inflammation.  Hemorrhage  rarely  attends 
this  phenomenon,  as  the  thrombus  usually  extends  beyond  the  area 
perforated,  thus  preventing  egress  of  the  blood. 

The  recognition  of  thrombophlebitis  is  entwined  with  no  great 
difficulties,  except  with  regard  to  h-mphangitis,  which,  considering 
the  anatomical  relationship  the  enmeshing  lymph  channels  bear  to  the 
veins,  is  eas}"  to  understand.  Yet  the  red  streaks  so  characteristic  of 
lymphangitis  should  make  differentiation  possible.  Confusion  may 
arise  when  the  latter  is  attended  with  the  formation  of  hard  cord  like 
thrombolymphangitis  and  abscess  formation.  Deep  phlebitis  is  mani- 
fested by  circulatory  sta.sis  and  edema.  The  veins  are  painful,  tender, 
and  frequently  palpable  as  hard  cords  corresponding  to  their  anato- 
mical location.    Consideration  of  a  causative  factor  is  helpful. 

The  clangers  of  suppurating  thrombophlebitis  are  twofold,  and  lie, 
first,  in  its  extension  along  the  coiirse  of  the  veins.  In  this  way 
thrombophlebitis  of  the  lip  —  through  the  facial  and  ophthalmic  veins 
and  the  cavernous  sinuses  —  and  phlegmonous  inflammations  of  the 
scalp  —  through  the  diploe  and  emissaries  of  Santorini  —  invade  the 
meninges.  In  a  similar  manner,  fatal  peritonitis  in  the  newborn  is 
caused  by  extension  of  the  infection  through  the  veins  of  the  um- 
bilicus. Thrombophlebitis  of  the  puerperal  uterus  progresses  through 
the  spermatic  and  hypogastric  veins  to  the  common  iliac  and  femoral, 
and  onto  the  inferior  vena  cava.  At  times,  the  inflammatory  formation 
of  the  thrombus  extends  against  the  blood  stream.  Thrombosis  of  the 
mesenteric  veins  complicates  perityphlitis,  appendicitis,  and  severe 
enteritis,  the  process  not  infrequently  extending  to  the  portal  system. 

The  second  danger  relates  to  the  loosening  of  hacteria  hearing  em- 
boli. These  emboli  originate  from  disintegrating  thrombi,  and  thus 
thrombophlebitis  becomes  the  cause  of  metastatic  infection.  Trauma- 
tism or  active  motion  may  provoke  dislodgement  of  an  embolus,  and 


286  INFECTIONS  OF  WOUNDS 

as  thrombi  are  always  fertilized  with  cocci,  this  danger  must  especially 
be  taken  into  account  in  the  treatment  of  pyogenic  processes. 

The  treatment  of  acute  thrombophlebitis  is  directed  toward  the 
complete  immobilization  of  the  affected  part.  Complicating  abscesses 
are  of  course  incised  and  drained. 

When  the  occurrence  of  chills,  remittent  fever  with  high  exacerba- 
tions, general  malaise  and  evidence  of  lung  emboli  indicate  the  break- 
ing down  of  a  pyogenic  thrombus,  early  ligature  and  section  of  the 

CENTRAL  PORTION  OF  THE  VEIN,  TOGETHER  WITH  RESECTION  OF  THE 
THROMBOSED  PORTION  AND  DISTAL  LIGATURE,  MAY  OBVIATE  FATAL  INFEC- 
TION. The  measure  has  succeeded  in  a  considerable  number  of  cases. 
Early  successes  were  attained  by  W.  Miiller^^  who  attacked  the  super- 
ficial veins  of  the  arms  and  thighs.  The  transverse  and  the  sigmoid 
sinuses  have  been  treated  frequently  in  this  manner.  Perhaps  the  most 
daring  effort  is  that  of  Trendelenburg,^^  who  successfully  li gated  the 
right  hypogastric  and  spermatic  veins  in  a  case  of  chronic  general 
infection  originating  in  the  uterus; 

E.  PYOGENIC  INFECTIONS  OF  BONES 

General  Considerations. —  Purulent  infection  of  the  osseous  system 
occurs  in  three  ways:  First,  immediately  sequential  to  trauma  (acci- 
dental or  operative  wounds  that  denude  the  bones  of  periosteum)  ; 
second,  by  the  extension  of  contiguous  inflammations  of  soft  parts 
(panaritium,  phlegmon,  purulent  arthritis,  suppuration  of  facial 
sinuses,  etc.)  ;  and  third,  by  way  of  the  Mood  stream  (hematogenous). 

The  terminology  of  the  pyogenic  inflammatory  process  attacking 
hone  is  best  based  on  the  tissue  exclusively  or  dominantly  involved. 
Periostitis  —  when  the  covering  of  the  bone  is  involved;  osteomyelitis 
—  when  the  bone  marrow  of  the  diaphysis  and  the  spongy  sections  are 
the  seat  of  infection;  and  ostitis,  when  the  cortex  is  inflamed.  As, 
however,  the  several  parts  of  the  bone  are  frequently  affected  simul- 
taneously, the  terms  "osteomyelitis"  and  "ostitis"  are  utilized 
to  describe  this  coexistence.  The  addition  of  purulent  (acute,  chronic) 
is  used  to  identify  suppurative  infection.  In  specific  infections,  the 
terms  "osteomyelitis  tuberculosa,"  "gummatosa,"  etc.,  are  used. 

The  causative  excitants  include  all  the  pyogenic  microorganisms. 
Ectogenous  infection  and  those  provoked  by  extension  are  due  to 
staphylococcus  and  streptococcus  invasions,  at  times  associated  with 
other  bacteria  (putrefactive  bacteria). 

The  hematogenous  form  is  most  often  caused  by  the  staphylococcus 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     287 


9  _ 
Fig.      124.  —  Suppurative 

Osteomyelitis    of    the 

Tibia         (semidiagram- 

matic). 

a,  Attachment  of  capsu- 
lar ligament;  h,  purulent 
focus  in  metaphysis,  which 
has  ruptured  into  the 
epiphysis;  e,  periosteum 
raised  by  pus ;  d,  phlegmon 
of  the  medulla ;  e,  separa- 
tion of  the  epiphysis;  /, 
axtracapsular  rupture  of 
pus;  g,  capsular  ligament; 
h,  rupture  into  joint. 


'pyogenes  aureus;  mixed  infections,  with  al- 
l)us  or  the  streptococcus  pyogenes,  come  next 
ill  frequency.  Occasionally  the  white  coccus 
or  the  streptococcus  is  the  lone  excitant. 
At  times  typhoid  and  colon  bacilli,  gonococci, 
influenza  and  pneumonia  hacilli,  and  the 
pneumococcus  are  provocative  of  bone  in- 
fection. However,  recent  investigation  iii 
this  connection  would  seem  to  show  that  bone 
lesions  are  more  frequently  caused  by  the 
last  named  microorganism  than  has  been 
generally  believed. 

The  pathological  changes  attendant  upon 
bone  infection  are  the  same,  irrespective  of 
whether  the  inflammation  attacks  from  with- 
'out  or  originates  within  the  marrow.  When 
infection  of  the  bone  occurs  from  without, 
following  trauma,  or  by  extension  of  a  phleg- 
monous inflammation,  the  periosteum  is  pri- 
marily affected.  This  membrane  swells,  be- 
comes red  in  color,  and  is  raised  from  the 
underlying  bone  by  a  layer  of  purulent  exu- 
date ;  following  this,  the  Haversian  canals  in 
the  cortex  of  the  bone  are  invaded.  Exten- 
sion of  the  process  to  the  marrow  frequently 
occurs  in  flat  bones,  following  suppuration 
in  a  contiguous  joint,  and  in  compound  frac- 
tures. 

In  hematogenous  infections,  the  inflam- 
matory process  usually  originates  in  the  bone 
marrow  of  the  diaphysis  or  in  the  spongy 
areas  of  the  skeleton,  rarely  in  the  cortex  or 
the  periosteum.  In  this  form  the  infection 
spreads  in  various  ways  (Fig.  124).  Pro- 
gressive purulent  disintegration  of  the  bone 
marrow  {hone  marrow  phlegmon)  is  fre- 
quently arrested  at  the  cartilaginous  junc- 
tion of  the  metaphysis ;  however,  a  pyogenic 
focus  located  near  this  point  may  cause :  (1) 
A  phlegmon  of  the  marrow;  (2)  extension 
along  cartilaginous  partitions  and  separation 


288 


INFECTIONS  OF  WOUNDS 


of  the  epiphysis;  (3)  penetration  through  the  nutritive  vessel 
canals  and  invasion  of  the  epiphysis;  (4)  perforation  of  the  epi- 
physis and  extension  to  the  joint;  or  (5)  perforation  of  the  cortex 
and  periosteum  near  the  cartilaginous  partition,  and,  according 
to  its  location,  breaking  through  within  or  without  the  capsule  of  the 
joint.  Phlegmon  of  the  bone  marrow  usually  spreads  symmetrically, 
finds  ready  exit  tliTough  the  haversian  canals, 
and  provokes  suppurative  periostitis.  The  pur- 
ulent exudate  soon  lifts  the  periosteum  and  per- 
forates it  at  a  necrotic  area.  The  compact  bony 
substance  which  is  now  bathed  in  pus  on  its  in- 
ner and  outer  aspects  is  dissociated  from  its  de- 
tached periosteum  on  the  outer  surface,  and  be- 
ing no  longer  nourished  by  the  marrow  (which 
is  degenerated)  undergoes  necrosis  {necrosis 
totalis).  When  only  the  inner  layers  of  the 
shaft  of  the  bone,  or  onl}^  certain  areas  of  the 
spongy  portion,  become  necrotic,  the  lesion  is 
called  central  necrosis.  When  the  lesion  corre- 
sponds to  a  restricted  subperiosteal  area  of  the 
bone  cortex,  it  is  called  cortical  necrosis. 

Dead  bone  tissue,  the  result  of  a  pyogenic  in- 
fection, becomes  bloodless,  white  in  color,  infest- 
ed with  bacteria,  and,  by  irritation,  provokes  in 
its  environment  a  reactive  inflammation  which 
takes  on  a  rarefying,  demarcating ,  or  osteoplas- 
tic form. 

Where  the  dead  and  living  tissues  are  in  con- 
tact, granulations  spring  from  the  marrow  of  tlie 
diaphysis,    from   the   spongiosa,    and   from   the 

haversian  canals.     This  reparative  proliferation   Ym.    125. Tubular 

of  connective  tissue  gradually  separates  the  dead  Sequestrum. 

portion  (sequestrum)  from  the  intact  bone,  and 

ultimately  the  former  is  surrounded  by  an  interspace  filled  with 
pus  and  granulation  tissue  (demarcation  trench).  The  peculiar, 
irregular,  worm  eaten  appearance  of  an  old  sequestrum  (Fig,  125)  is 
due  to  the  digestive  action  of  the  granulation  tissue  (by  ferments). 
The  en  masse  and  central  sequestra  of  the  diaphysis  are  tuhular  in 
form,  the  cortical  take  on  the  outlines  of  disTis  or  splinters.    Complete 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     289 


separation  of  a  sequestrum  is  a  time  cousuming  process,  varying  — 
in  accord  with  its  size  —  from  weeks  to  six  months  or  longer.  Loosened 
sequestra,  when  superficially  located,  may  be  spontaneously  expelled; 
usually,  however,  they  remain  in  situ  for  years, 
constantly  subjected  to  the  action  of  the  granu- 
lation tissue,  which  succeeds  in  accomplishing  ab- 
sorption only  when  the  sequestrum  is  small. 

While  the  sequestrum  is  being  separated  and 
subjected  to  the  digestive  action  of  the  granula- 
tions, the  inflammatory  reaction  also  provokes 
the  growth  of  new  bone.  In  this  osteogenesis, 
the  periosteum  plays  the  major  part,  and  the 
bone  marrow  and  contiguous  intermuscular  con- 
nective tissue  are  secondarily  concerned.  Bone 
regeneration  is  most  rapid  in  the  long  hollow 
bones  and  slowest  in  the  flat  bones.  Early  in  the 
cycle  of  events,,  often  at  the  end  of  a  week,  thin 
layers  of  bony  deposit  appear  upon  the  under 
side  of  the  periosteum  (periostitis  ossificans). 
Gradually,  after  months,  the  persistence  of  in- 
flammatory irritation  provokes  the  production  of 
a  bony  shell  which  is  at  first  thin,  friable,  and 
porous  (like  amber),  but  later  is  uniform  in  out- 
line and  sclerotic.  This  involucrum  (capsula 
sequestralis)  incases  the  sequestrum  and  is  sep- 
arated from  it  by  a  thin  layer  of  granulation  tis- 
sue and  thickened  pus.  The  involucrum  is  ir- 
regularly studded  with  perforations  {cloacae) 
(Fig.  126)  that  are  lined  with  granulations  and 
give  egress  to  the  exudate  (from  within)  which 
reaches  the  surface  through  canals  (fistulae)  in 
the  overhing  soft  parts.  In  situations  where 
wide  areas  of  periosteum  are  destroyed,  the  for- 
mation of  involucrum  is  defective,  leaving  un- 
supported spaces  which  predispose  to  pathologi- 
cal fracture  and  pseudo-arthrosis.  When  the  in- 
volucrum becomes  sclerotic,  the  formation  of  new  bone  ceases.  At 
times  the  activities  of  the  bone  marrow  cause  a  thickening  of  the 
spongiosa  and  the  compact  tissue  of  the  bone  (osteomyelitis  ossifi- 
cans), that  takes  on  the  character  of  ivory.     This  eburnation  may 


W^ 


Fig.  126. — Necrosis  of 
Humerus  ;  Ixvolu- 
CEUM  WITH  Cloacae. 


290  INFECTIONS  OF  WOUNDS 

surround  a  purulent  focus  or  a  sequestrum  of  the  entire  shaft  of  a 
long  bone. 

The  course  taken  and  the  clinical  picture  presented  by  purulent 
infections  of  bone  are  exceedingly  variable,  and  are  dependent  upon 
the  virulence  of  the  excitants,  the  lack  of  local  and  constitutional 
resistance  of  the  host,  the  site  of  the  original  focus,  the  occurrence  of 
Irauma,  complicating  joint  involvement,  and  the  coexistence  of  other 
metastatic  foci. 

Osteomyelitis. — Osteomyelitis  purulenta  of  hematogenous  origin  is 
the  form  most  commonly  met  with,  and  its  development  has  been  made 
the  object  of  numerous  experiments. 

A  small  quantity  of  virulent  staphylococcus  pyogenes  aureus  cidture 
injected  into  the  blood  (vein)  of  a  rabbit  or  guinea  pig  is  followed 


Fig.  127. —  Eontgenogram  of  Necrosis  Totalis  of  Humerus   (Stewart;. 

by  severe  fehrile  disturhances  and  death.  Autopsy  shows  the  various 
organs,  muscles,  hones,  and  joints  more  or  less  freely  studded  with 
purulent  foci.  The  smaller  the  doses  of  bacterial  culture,  the  less  is 
the  proportion  of  foci  in  the  organs  of  the  body  as  compared  to  those 
in  the  bones,  which  latter  are  especially  marked  in  the  broad  meta- 
physes  of  the  femora  and  tibiae  near  the  knee  joints,  and  in  the  upper 
humerus   ( Lexer ^^ ) . 

The  same  phenomena  follow  the  introduction  of  cultures  of  staphy- 
lococcus pyogenes  albus,  streptococcus  pyogenes  (Lexer^"),  and  bac- 
terium coli  communis  (Ackermann^^). 

When  old,  enfeebled  cultures  of  cocci  are  injected,  the  animal  re- 
covers after  a  short  illness,  during  which  painful,  hot  swelling  of  one 
or  more  joints  has  occurred.     While  the  swelling  of  the  soft  parts 


PYOGENIC  INFECTIONS  OF  VAKIOUS  TISSUES      291 

about  the  joints  gradually  disappears,  the  thickening  of  the  bone 
slowly  increases  and,  at  the  end  of  two  to  three  months,  develops  into 
a  condition  which  in  man  is  known  as  chronic  purulent  osteomyelitis 
and  is  attended  with  pyogenic  degeneration  and  necrosis  (Lexer^'^). 

The  experimental  injection  of  pyogenic  bacteria  is  followed  by  acute 
progressive  phlegmonous  osteomj'elitis  0)ily  when  the  hone  of  the 
animal  has  been  previously  infected  with  pus  organism  indigenous  to 
it  (Lexer''-). 

Trauma  has  also  a  determining  influence.  "When  fracture  of  a 
bone  is  followed  by  the  injection  of  pyogenic  cocci,  purulent  inflam- 
mation rapidl}'  develops  at  the  site  of  the  injury  (Ullmann^^). 

Animal  experimentation  would  seem  to  indicate  that  pyogenic  bac- 
teria (especially  staphylococci)  are  conveyed  by  the  blood  stream  to 
the  bones  of  the  young,  where  they  lodge,  preferably  in  the  metaphy- 
sial areas  at  the  site  of  a  traumatic  hemorrhage  {locus  minoris  resis- 
tentiae)  and  there  provoke  purulent  inflammation. 

Bacteria  gain  access  to  the  Mood  stream  iy  absorption  from  inflam- 
matory foci,  as  constituents  of  blood  clots  {infected  emboli),  or  are 
derived  en  masse  (bacterial  emboli)  from  the  thrombosed  veins  of  a 
primary  focus.  Purulent  estfections  of  bone  are  always  second- 
ary, EVEN  THOUGH  THE  SKVT  OF  THE  PRIMARY  CAUSATIVE  FOCUS  IS  NOT 

DISCOVERABLE  (Jordan  ^"'). 

However,  the  absorption  of  bacteria,  which  always  attends  every 
infection  of  tissue,  is  followed  by  purulent  osteomyelitis  only  under 
certain  conditions.  Excitants,  unless  introduced  into  the  blood  in 
large  numbers  or  over  a  long  period  of  time,  are  deposited  by  the 
circulating  fluid,  in  the  bone  marrow,  the  spleen,  and  the  liver,  where, 
especially  in  the  bone  marrow,  they  come  in  contact  with  the  bacteri- 
cidal substances  derived  from  the  leukocytes.  Here  they  are  destroyed 
or  remain  without  developing  pathogenesis.  As  the  bone  marrow  is 
largely  concerned  in  furnishing  the  specific  immune  bodies  active  in 
combating  many  infections,  the  deposit  of  bacteria  within  it  stimu- 
lates it,  partly  mechanically,  and  partly  by  biochemical  action  to  fur- 
nish these  bodies  to  the  entire  organism.  Indeed,  "Weichselbaum'^  (and 
later  E.  Fraenkel)  succeeded  in  isolating  from  the  bone  marrow  of  the 
cadaver  the  excitants  of  pneumonitis,  phlegmon,  and  erysipelas,  though 
no  evidence  of  general  infection  existed.  From  this  it  would  seem  justi- 
fiable to  conclude  that  the  bone  marrow  contains  bacteria  in  cases  of 
moderate  local  infection. 

Purulent  inflammation  follows  the  invasion  of  pyogenic  bacteria, 


292 


INFECTIONS  OF  WOUNDS 


first,  when  the  bacteria  are  of  a  virulent  strain,  and  are  present  in 
such  large  numbers  that  the  bactericides  are  overcome ;  and,  second, 
when  trauma  has  lessened  the  bactericidal  ca- 
pacity of  the  bone  marrow.  To  these  may  be 
added  a  third  mode  of  development  of  pyo-  a 
genous  bone  inflammation  —  the  migration  of 
infected  or  bacterial  emboli  from  the  primary 
inflammatory  focus  which  always  contains 
veins  and  thrombi  fertilized  with  bacteria. 
Embolic  invasion  of  this  sort  occurs  at  the 
hranching  of  nutritive  arteries  near  the  zone 
of  growth  of  the  long  bones  where  all  the  ves- 
sels terminate  (Fig.  128),  and  in  the  short  flat 
bones  which  are  frequently  the  seat  of  tuber- 
culosis infection  (vertebrae,  pelvic  bones, 
phalanges,  etc.)  (Lexer^'^).  As  the  latter 
bones  are  invaded  by  pyogenic  processes  much 
less  frequently  than  by  tuberculosis,  embolic 
infection  is  probably  less  of  a  factor  in  the 
former  than  in  bone  tuberculosis. 

The  fact  that  the  metaplujses  of  long  hones 
are  more  frequently  the  seat  of  purulent  foci 
than  are  other  portions  of  the  osseous  system 
cannot  be  explained  on  the  ground  that  the 
bacteria  are  held  fast  in  this  situation  with 
the  help  of  bactericidal  substances,  for  it  is 
fair  to  assume  that  the  diaphysis  is  no  weaker 
in  this  regard,  than  is  the  metaphysis ;  nor  can 
embolic  infection  be  explained  on  this  basis,  pkj.  128.— Femur  of  a 
as  other  bones  are  much  less  often  attacked  in  Child  Four  Weeks  Old, 
this  way.     On  the  other  hand,  the  wealth  of 

BLOOD  VESSELS  IN  THE  LONG  BONES  OF  THE 
TOUNG,  THE  PHYSIOLOGICAL  HYPEREMIA  IN  THE 
ZONE   OF   GROW^TH,    AND   THE   ARRANGEMENT   OF 

THE  ARTERIES  AND  CAPILLARIES  in  the  uarrow 

„  ,,  .  M      •  •    T,      •      ^^^t-      fl,  Epiphyseal  arteries;  &, 

spaces  of  the  cartilaginous  epiphysis,  present    jnetaphyseal     arteries;      c, 

mechanical  conditions  exceedingly  favorable  double  nutrient  arteries. 
to  the  deposit  of  bacteria. 

The  frequency  with  which  staphylococci  occur  as  causative  excit- 
ants may  be  ascribed  to  their  peculiar  method  of  group  multiplication. 


THE  Vessels  of  Which 
Have  Been  Injected,  as 
Seen  in  a  Kontgen  Ray 
Picture  (Periosteum 
AND  Capsular  Liga- 
ments Dissected 
Away). 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      293 

When  these  organisms  are  slowly  propelled  through  the  capillary  sys- 
tem of  the  cartilage,  they  have  ample  opportunity  to  gather  in  groups, 
and  when  several  of  these  coalesce  within  the  lumen  of  a  small  vessel, 
conditions  are  propitious  for  the  development  of  a  pyogenic  focus 
(Dumont^'). 

The  preponderance  of  yellow  staphylococci  in  hone  infections,  as 
compared  to  the  white,  is  due  to  the  greater  pathogenicity  of  the 
former. 

To  summarize :  hematogenous  purulent  osteomyelitis  is  due  first,  to  the 
colonization  of  virulent  pyogenic  bacteria  in  the  bone  marrow;  second,  to  the 
deposit  of  infected  and  bacterial  emboli;  and  third,  to  the  coalescence  of 
staphylococcus  groups  in  the  small  blood  vessels  of  the  bones.  Trauma  may 
be  regarded  as  a  fourth  predisposing  cause. 

The  causative  relatwnship  between  trauma  (fracture,  contusion, 
effect  of  cold)  and  purulent  osteomyelitis  is  threefold:  First,  pyogenic 
bacteria  circulating  in  the  blood  are  conveyed  to  the  site  of  the  injury 
(locus  minoris  resLstentiae;  ;  second,  trauma  is  directed  against  a 
bone  in  which  pyogenic  bacteria  are  quiescent ;  and  third,  the  trauma 
ruptures  the  encapsulation  of  an  old  focus. 

The  seat  of  purulent  osteomyelitis  and  the  ages  at  which  it  occurs 
are  widely  diversified.  It  occurs  most  frequently  during  the  period 
of  greatest  body  growth  —  eight  to  seventeen  years  of  age;  after  the 
twenty-fifth  year  it  is  rare. 

This  accords  with  the  finding.s  of  animal  experimentation.  Young 
animals  injected  with  staphylococci  develop  purulent  foci  in  the 
bones  (together  with  other  foci),  while  in  adult  animals,  the  lesions 
occur  in  the  joints  but  are  never  intra-osseotis,  and  rarely  subperiosteal 
(Lexer-®).  This  is  ascribable  to  the  great  vascularity  of  young  bones 
(Fig.  129)  as  compared  to  those  of  the  adult,  and  also  to  the  histo- 
logical structure  of  the  richly  cellular  marrow  of  the  bones  of  the  young 
in  contrast  to  the  fatty  consistency  of  those  of  the  adult. 

The  seat  of  purulent  osteomyelitis  is  usually  in  that  portion  of  the 
long  tubular  bones  most  actively  engaged  in  growth.  Lesions  occur 
(according  to  Gangolphe^-)  in  the  lower  metaphysis  of  the  femur,  the 
■upper  humerus  and  the  lower  tibia,  in  the  stated  order  of  frequency. 
In  the  epiphysis  of  long  tubular  bones,  in  the  short  and  in  the  flat 
hones,  that  is  to  say,  in  bones  often  the  seat  of  tuberculosis,  suppura- 
tive osteomyelitis  infrequently  occurs.  Several  bones,  or  more  than 
one  sector  of  the  same  bone,  may  be  simultaneously  attacked. 

Clinically,  the  widely  varied  picture  of  osteomyelitis  purulenta  pre- 


294  INFECTIONS  OF  WOUNDS 

sents  itself  in  acute  and  in  chronic  forms;  it  is  associated  with  a  num- 
ber of  complicatio7is,  is  the  outcome  of  diversified  causative  factors, 
and  is  the  result  of  the  invasion  of  many  classes  and  strains  of  bacteria. 

Hematogenous  osteomyelitis  purulenta  acuta  begins  suddenly  and 
folloivs  a  stormy  course.  Previously  healthy  children,  as  well  as  those 
debilitated  from  various  causes  (malnutrition,  infectious  diseases,  etc.), 
complain  of  sudden  severe  pain  in  a  definite  region.  The  initial  pain 
is  usually  located  near  a  joint,  is  attended  with  chill,  high  fever,  and 
loss  of  function  of  an  entire  limb. 

The  causative  factor  is  not  always  apparent,  though  the  process 
is  often  preceded  by  trauma,  and,  at  times,  by  chronic  hone  infection, 
to  which  trauma  is  added.  In  rare  instances,  purulent  osteomyeltitis 
develops  at  the  site  of  a  simple  fracture,  when 
the  patient  is  at  the  same  time  afflicted  with  an 
acute  inflammation  elsewhere  (angina). 

The  fever  is  continuous  in  character,  and  is  at- 
tended with  very  severe  general  disturbances. 
In  a  day  or  two  the  afflicted  limb  becomds 
swollen,  slightly  reddened,  edematous,  and 
tense  or  fluctuating;  presenting  a  condition  sim-  Fig.  129.  —  Intra- 
ilar  to  that  produced  by  a  phlegmonous  inflam-  iococcus  ^'^Focus 
mation  of  the  soft  parts.  The  hone  appears  in  the  Neck  of 
thickened  to  palpation,  but  this  is  due  to  the  ex-  broken  Through 
udate  in  the  soft  parts.     The  subcutaneous  veins  (Two  year  old 

are  engorged,  the  contiguous  lymph  glands  en-  c  ic;. 

larged  and  tender.  A  false  point  of  motion,  due  to  epiphyseal  opera- 
tion, may  be  elicited  in  ten  to  fifteen  per  cent  of  the  cases  (Garre,^^ 
Reiss'*°).  Neighboring  joints  are  frequently  invaded  (see  complica- 
tions). 

Early  operative  exposure  of  the  lesion  shows  the  soft  parts  (es- 
pecially the  intermuscular  septa)  surrounding  the  bone  saturated 
with  serous  exudate,  or  in  a  condition  of  purulent  phlegmonous  in- 
flammation;  the  periosteum,  discolored  and  raised  from  the  hone  hy 
purulent  exudate,  the  hone  presenting  a  devitalized  blanched  appear- 
ance. The  periosteum  is  capable  of  osteogenetic  proliferation  in  pro- 
portion to  the  extent  to  which  it  remains  connected  with  the  surround- 
ing soft  parts.  Close  scrutiny  reveals  pus  oozing  from  the  vascular 
canals  at  the  metaphysis ;  the  pus  is  derived  from  the  bone  marrow  and 
usually  contains  small  fat  glohules.  At  first,  the  bone  marrow  is 
deep  red  in  color,  flaked  with  small  insular  collections  of  pus;  dis- 


PYOGENIC  INFECTIONS  OF  VAKIOUS  TISSUES     295 

iinctly  purident  foci  appearing  only  at  the  epiphyseal  cartilage;  later, 
the  entire  medulla  is  converted  into  a  mass  of  yellowish  green  pus, 
which  the  microscope  shows  to  be  freel}'  infested  with  cocci. 

In  most  of  the  severe  cases  of  the  midtiple  form  of  the  disease — ■ 
which  comprise  about  tweut}'  per  cent  (Garre^'*),  the  lesions  appear 
in  bones  not  commonly  invaded,  as  well  as  in  those  usually  affected. 
The  infection  develops  as  part  of  a  general  metastatic  process  de- 
rived from  a  primary  causative  focus,  or  may  be  sequential  to  the  first 
bone  lesion  (Garre^^).  Clinically,  the  lesions  may  appear  in  rapid 
succession  or  at  long  intervals,  at  times  are  attended  with  acute  mani- 
festations, and,  at  others,  take  on  the  form  of  chronicity.     Multiple 

ACUTE  OSTEOMYELITIS,  LIKE  THE  HEMATOGENOUS  FORM,  IS  A  PYOGENOUS 
METASTATIC  GENERAL  INFECTION  OF  YOUTH,  CHARACTERIZED  BY  THE 
SUSCEPTIBILITY  OF  BONE  MARROW  TO  THE  DE\T:L0PMENT  OF  METASTATIC 
INFLAMMATIONS. 

Hematogenous  acute  purulent  periostitis  usually  develops  in  con- 
nection with  small  cortical  foci  situated  in  flat  bones,  or  in  the  region 
of  the  metaphyses  of  large  tubular  bones.    The  adult  is  not  exempt. 

The  frequent  involvement  of  joints  consequent  to  localized  acute 
osteomyelitis  of  the  joint  regions  has  caused  these  lesions  to  be  con- 
sidered under  a  separate  head  (Midler").  These  miniature  foci 
usually  occur  in  young  children  (up  to  five  years  of  age).  Like 
tuberculosis  foci,  they  are  located  in  the  metaphyseal  area,  close  to 
where  the  vessels  entering  the  side  of  the  epiphyseal  cartilage  divide. 
The  vessels  entering  the  femur  at  the  ligmentum  teres,  and  those 
entering  the  tibia  at  the  crucial  ligaments,  are  frequently  the  avenues 
of  approach  in  this  connection.  The  lesions  are  located  in  the  perios- 
teum, in  the  cortex,  or  may  be  intra-osseal.  The  carpal  and  tarsal 
bones  are  not  infrequently  invaded.  In  the  hip  joint,  the  focus 
usually  lodges  in  the  upper  angle  of  the  Y-shaped  epiphyseal  cartilage. 
The  causative  excitants  are  staphylococci  and,  relatively  frequently, 
strepto-  and  pneumococci  (Lexer*-). 

The  clinical  picture  of  the  lesion  is  dominated  b}'  the  purulent 
inflammaiion-  of  the  joint,  or,  when  extracapsular  rupture  takes  place, 
by  the  symptoms  of  a  periarticular  phlegmon.  The  causative  focus 
is  usually  not  suspected  until  operative  measures  uncover  it.  It  should 
be  excavated  thoroughly  with  the  view  of  obviating  destruction  of  the 
epiphysis  and  reinfection  of  the  joint. 

A  rare  form  of  osteomyelitis  and  periostitis  serosa  (albuminosa  of 
Oilier*^)    involving  the  upper  tibia   is  due  to   the  invasion   of  the 


296 


INFECTIONS  OF  WOUNDS 


staphylococcus  alhiis  and  of  streptococci.  It  begins  acutely,  but  soon 
becomes  chronic  and  develops  large  periosteal  abscesses  and  inflam- 
matory areas  in  the  spongiosa  which  lead  to  the  formation  of  sequestra. 
The  lesion  is  not  attended  with  suppuration,  but  by  the  transudation 
of  a  serous  or  mucovitreous  exudate.  Schlange**  explained  the  char- 
acter of  exudate  on  the  ground  that  the  excitant  possessed  only  mod- 
erate virulence.  VoUert^'^  and  Garre^^  suggest  that  a  purulent  exu- 
date may  be  converted  into  one  possessing  a  mucoid  consistence. 

The  thickened  membrane  of  a  periosteal  abscess  may  simulate  bone 
cyst  (ganglion  periostale),  and  on  the  skull  has  been  mistaken  for 
meningocele.     The  superficial  necrosis  of  the  bone  and  demonstration 

of  the  presence  of  pyogenic  bacteria  clear  up  the  diagnosis. 

Of  the  complications  of  acute  suppura- 
tive osteomyelitis,  involvement  of  joints 

is  the   most   frequent.     This   occurs   in 

three  ways :     First,  following  rupture  of 

a  purulent  -focus  of  the  epiphysis  or  of  a 

medullary  phlegmon  into  the  joint,  and 

consequent    acute    purulent    synovitis; 

second,     metastatic    joint     involvement 

originating  in  a  primary  bone  lesion,  in 

which  event  the  exudate  may  be  serous 

or    purulent;    and   third,    the   so-called 

sympathetic   form   of   serous   synovitis, 

due  to  the  action  of  toxins,  which  ap- 
pears as  an  intermittent  joint  hydrops 

and  is  dependent  upon  the  presence  of 

an    encapsulated     (acute     or    chronic) 

focus  in  the  epiphysis. 

Pressure  and  distention  of  the  synovial  exudate  may  cause  luxation 

of  the  joint. 

Aspiration  and  immobilization  of  a  joint  filled  with  serous  exudate 

may  be  followed  by  recovery.     These  measures  rarely  suffice  when 

suppuration  occurs,  in  which  instance  early  incision  and  drainage  is 

imperatively  indicated.     Destruction  of  the  epiphysis  and  articular 

cartilages  following  rupture  into  the  joint  of  a  severe  phlegmonous 

inflammation  of  the  shaft  of  the  bone  may  make  resection  of  the  joint 

necessary  (see  diseases  of  joints). 

General  infection  is  the  most  menacing  complication  of  this  disease. 

When  bacteremia  attends  infection  of  one  or  more  bones,  it  is  not 


Fig.  130. — •  Pneumococcic  Focus 
IN  Lower  Articular  End  of 
THE  Femur  of  a  Child  Nine 
Months  Old. 

P,    Eupture    through    the    epi- 
physis; K,  capsule  of  joint. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      297 


certain  whether  the  presence  of  bacteremia  in  the  blood  is  due  to  the 
bone  lesion,  or  whether  the  bone  lesions  are  a  part  of  the  bacteremia. 
At  times  bone  lesions  are  not  characterized  by  suppuration,  but  the 
medulla  presents  hemorrhagic 
foci  surrounded  hy  zones  of  se- 
vere hyperemia  {acute  hemor- 
rhagic osteomyelitis). 

Metastatic  pyogenic  infection 
of  the  serous  cavities  and  joints, 
and  the  deposit  of  purulent  foci 
in  the  organs  and  muscles  indi- 
cate fatal  metastatic  general  in- 
fection. A  primary  bone  lesion 
may  bear  a  causative  relation- 
ship to  this  condition,  or  the  in- 
vasion of  the  osseous  system  may 
be  a  part  of  a  general  process, 
the  initial  lesion  of  which  is  lo- 
cated elsewhere. 

Additional  complications  oc- 
cur in  accord  with  the  location 
of  the  particular  bone  involved, 
i.  e.,  osteomyelitis  of  ribs  ex- 
tends to  the  pleura,  that  of  the 
bones  of  the  skull  invades  the 
meninges,  etc. 

The  course  of  the  disease,  j^. 
when  stormy  and  attended  with 
a  general  infection,  reaches  a 
fatal  termination  in  a  week  (the 
articular  typhus  of  the  French 
writers).  Ordinarily,  fever  and 
the  concomitant  constitutional 
symptoms  disappear  after  the 
infected  bone  is  freely  drained 
or  spontaneous  expulsion  of  the 


Ci. 

Fig.  131. —  Severe  Osteomyelitis  op 
THE  Femur  in  a  Child  Nine  Weeks 
Old,  Caused  by  Streptococci  (three 
weeks  after  the  beginning  of  the 
disease). 

K,  Center  of  ossification ;  H,  sup- 
purating focus;  Ci,  internal  condyle; 
P,  perforation ;  W,  periosteal  bone  form- 
ation; S,  sequestration. 


exudate  occurs.  In  the  sub- 
acute form,  encapsulation  occurs  in  a  few  days  and  is  followed  by 
subsidence  of  the  symptoms.  However,  acute  purulent  osteomyelitis 
must  always  he  regarded  as  a  serious  affliction,  involving  as  it  does  the 


298  INFECTIONS  OF  WOUNDS 

dangers  of  metastases,  general  infection,  and  complications  of  varyin^^ 
severity,  all  of  which  threaten  life,  and  the  destruction  of  bones  and 
joints,  with  their  sequential  loss  or  modification  of  function. 

During  the  acute  febrile  stage  of  the  disease,  or  during  exacer- 
bations OF  fever,  the  presence  of  the  causative  excitants  may 
BE  demonstrated  (by  culture)  in  the  blood  (Garre,^^  Lexer"). 

The  recogyiition  of  hematogenous  acute  purulent  osteomyelitis  rests 
on  the  sudden  development  of  stormy  constitntional  symptoms  asso- 
ciated with  the  local  ynanifestations  of  a  severe  inflammatory  process. 
When  the  presentation  of  this  clinical  picture  is  accompanied  with 
deep  tenderness  and  infiltration  of  the  soft  parts,  not  traceable  to 
lymphangitis  or  to  the  infection  of  a  wound,  the  diagnosis  should 
not  be  difficult.  The  existence  of  a  port  of  entrance  of  the  infection, 
in  the  form  of  panaritium,  furuncle,  infected  lacerated  wounds, 
eczema,  abrasions,  peritonsillar  abscess,  otitis  media,  etc.,  may  be 
regarded  as  of  diagnostic  significance. 

Coiifusioti  in  diagnosis  arises  in  connection  with  deeply  located 
lymphangitis  and  phlegmon  of  lymphangitic  origin,  especially  in 
situations  where  bone  lesions  are  common  (the  popliteal  fossa,  Scarpa's 
triangle,  the  bicipital  fossa,  etc.),  and  where  hematogenous  suppura- 
tion in  muscldls  occurs.  Incision  clears  up  the  diagnosis;  if  the  perios- 
teum is  closely  adherent  to  the  bone,  the  latter  may  be  regarded  as  not 
involved. 

The  treatment  of  acute  purulent  osteomyelitis  involves  the  problem 
of  obviating  general  infection  and,  as  far  as  is  possible,  destruction  of 
bone  tissue.  The  earlier  the  inflammatory  process  is  exposed,  the 
better  is  the  outlook  in  this  connection. 

Under  complete  necrosis,  and  after  exsanguination  with  the  v. 
Esmarch  bandage,  the  soft  parts  are  carefully  (avoiding  nerves,  blood 
vessels,  etc.)  but  widely  divided,  the  muscles  being  separated  between 
the  planes  of  fascia  down  to  the  periosteum.  The  yellowish  perios- 
teum, which  is  found  raised  from  the  bone  by  purulent  exudate,  is 
opened  to  the  full  extent  of  the  suppuration.  When,  as  is  usually  the 
case,  pus  mixed  with  fat  globules  oozes  out  of  the  pores  of  the  cortex, 
the  medullary  canal  and  the  metaphyseal  spongiosa  are  opened  to  the 
full  extent  of  the  purulent  infiltrate.  Injury  to  the  capsule  of 
the  joint,  the  fracture  of  thin  bones,  and  trauma  to  the  epiphysis 
are  to  be  avoided.  If  involvement  of  the  epiphysis  demands  attack 
upon  it,  invasion  of  the  articular  cartilage  must  be  avoided.  The 
pultaceous,  purulent  medulla  and  the  infiltrated  spongiosa  are  removed 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     299 

with  the  spoon  and  by  means  of  gauze  wipes,  and  the  resultant  cavity, 
together  iv-ith  the  ivoioid  of  approach,  are  tamponed  with  iodoforms 
gauze.  The  dressing  should  be  applied  (especially  when  the  epiphysis 
is  separated)  with  the  view  of  preventing  deformity  during  the 
process  of  healing,  which  takes  from  three  to  five  months.  For  this 
purpose  immobilization  apparatus,  w^hich  wall  also  permit  of  frequent 
changes  of  dressings  (Avithout  disturbing  the  immobilizing  apparatus) 
may  be  readil}'^  devised  to  meet  the  indications. 

During  repair,  which  takes  place  by  granulation  and  bone  genesis, 
small  portions  of  dead  bone  may  be  exfoliated  at  intervals.  However, 
as  a  rule  most  of  the  bone  is  ultimately  replaced. 

Incision  of  the  soft  parts  without  removal  of  the  infected  bone,  or 
simple  drainage  of  the  medullary  canal  by  drilling  may  be  condemned 
without  qualification.  Insufficient  measures  of  this  sort  favor  the 
progress  of  the  purulent  inflammation,  extension  of  necrosis,  rupture 
into  the  contiguous  joints,  and  recurrence  of  general  sjTuptoms. 
When  entire  diaphyses  or  epiphyses  are  necrotic  and  separated  from 
the  contiguous  bone  tissue,  they  must  be  removed.  In  these  instances 
resection  of  the  infected  bone  area  is  followed  by  immobilization  as 
stated  above.  Despite  extensive  necrosis  of  the  periosteum,  bone  re- 
generation ultimately  takes  place  in  most  instances.  The  implanta- 
tion of  bone  grafts  into  the  granulating  cavity  stimulates  osteogenesis, 
although  subsequent  removal  of  the  implant  is  usually  necessary.  In 
the  flat  lones  (pelvis,  scapula,  ribs,  etc.)  resection  is  necessary.  In 
the  bones  of  the  skull,  the  diploe  must  be  scooped  out  and  the  laminae 
vitrea  opened  for  the  purpose  of  draining  subdural  pu3. 

In  severe  cases,  amputation  or  disarticulation  of  the  afflicted  limb 
is  at  times  indicated  in  order  to  save  life. 

Osteomyelitis  purulcnta  chronica  occurs  sequentially  to  the  acute 
form,  or  may  be  chronic  from  the  beginning.  The  so-called  independ- 
ent or  primary  chronic  form  follows  trauma;  periosteal  suppuration 
results  by  extension  from  chronic  inflammatory  processes  of  the  soft 
parts  contiguous  to  bone,  and  is  frequently  due  to  the  deposit  of 
bacteria  carried  to  the  bone  by  the  blood  current. 

When  the  acute  stage  of  the  disease  is  not  attended  with  compli- 
cations and  there  has  been  a  spontaneous  expulsion  of  pus,  or  a  simple 
incision  and  drainage  has  been  employed  for  relief,  nature  attempts 
to  expel  the  residual  necrotic  area  of  hone  hy  a  rarefying  and  osteo- 
plastic  inflammation  which  is  a  long-drawn-out  process  (six  months 
at  least).     The  consummation  of  this  end  is  not  attended  with  serious 


300  INFECTIONS  OF  WOUNDS 

disturbances,  unless  the  inflammation  extends  to  a  contiguous  joint, 
or  leads  to  a  belated  or  secondary  epiphyseal  separation.  From  time 
to  time,  when  the  fistulous  openings  are  temporarily  obstructed,  the 
occurrence  of  deep  seated  throhhing  pain  and  a  rise  of  temperature 
heralds  the  reaccumulation  of  suppurative  exudate.  During  this 
period  the  bone  presents  irregular,  insular  areas  of  thickening  which 
extend  over  a  part  or  throughout  its  entire  diameter.  Exacerbation 
of  the  process  provokes  a  large  increase  in  inflammatory  infiltrate  into 
the  surrounding  soft  parts  covered  by  slightly  reddened  skin.  The 
fistulae  are  lined  with  healthy  granulations  which  protrude  from  the 
openings,  in  contradistinction  to  the  pale,  flaccid  ones  common  to  bone 
tuberculosis.  The  breaking  down  of  the  exudate  may  be  accompanied 
with  the  discharge  of  small  sequestra.  The  ungentle  removal  of  rough 
spicula  may  be  attended  with  the  laceration  of  blood  vessels. 

When  areas  of  chronic  osteomyelitis  are  traumatized,  active  phleg- 
monous inflammation  of  the  contiguous  soft  parts  is  likely  to  happen. 
Bacteria  lying  dormant  in  granulation  or  scar  tissue  may  remain 
quiescent  for  years,  and  as  the  result  of  injury  may  be  suddenly  liber- 
ated into  the  surrounding  soft  parts,  and  thus  gain  access  to  the 
blood  stream. 

The  primary  or  independent  chronic  forms  of  the  disease  are  not 
infrequently  preceded  by  a  short  indeflnite  period  of  acuteness,  though 
this  may  be  absent.  Young  children  develop  moderate  febrile  move- 
ment, slight  redness  and  swelling  contiguous  to  one  or  more  joints, 
with  dull  —  not  very  severe,  pain  (growing  pains),  followed  a  few 
days  later  by  complete  subsidence  of  symptoms.  Years  later,  after 
adolescence  has  come  and  gone,  the  old  areas  become  painful  and 
thickened,  and  gradually  unfolds  the  typical  picture  of  a  more  or  less 
acute  bone  lesion  with  all  its  local  and  constitutional  symptoms  — 
including  purulent  arthritis,  and  phlegmonous  infiltration  of  soft 
parts. 

This  chronic  form  of  osteomyelitis  may  be  divided  into  three 
classes. 

1.  With  a  central  sequestrum^  a  thick  involucrum,  and  a  moderate 
degree  of,  or  no,  suppuration. 

2.  With  hone  ahscesses,  usually  situated  in  the  metaphyseal  region, 
encapsulated  within  heavily  thickened  sclerotic  layers  of  bone,  and 
varying  in  size  from  a  pea  to  a  hen's  egg.  The  centers  of  these 
lesions  contain  thick,  slimy  pus,  surrounded  by  a  dense  pyogenic 
membrane,  and  are  filled  with  dormant  staphylococci  that  are,  how- 


.     PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      301 

ever,  still  capable  of  resuming  pathogenicity  at  the  end  of  from  ten  to 
thirty  years, 

3.  Sclerotic  osteomyelitis  (Garre^")  which  begins  acutely,  or  sub- 
acutely,  and  never  suppurates,  showing  it  to  be  caused  by  bacteria 
possessed  of  but  moderate  virulence.  This  lesion  is  characterized  by 
the  development  of  a  painful  thickening  of  a  large  or  restricted  por- 
tion of  the  bone,  which  when  due  to  luetic  hyperostosis,  invades  its 
medullary  canal.  The  surface  of  the  bone  presents  an  irregular,  un- 
dulating outline;  at  times  tiny  purulent  and  granulating  areas  are 
found  widely  studding  the  sclerotic  bone  tissue,  and,  on  frequent  oc- 
casions, minute  central  sequestra  are  discernible. 

The  dangers  of  chronic  purulent  osteomyelitis  relate  to  the  acute 
exacerbations  consequent  to  the  infliction  of  trauma,  especially  when 
followed  by  various  local  and  constitutional  complications,  which  in- 
clude abscess  formation,  joint  inflammations,  and  remote  impairment 
of  function. 

Recognition  of  the  chronic  form  may  present  considerable  diffi- 
culty, especially  when  the  local  evidences  of  bone  lesion  are  not  par- 
ticularly clear.  The  X-ray  is  not  by  any  means  definitely  diagnostic. 
Confusion  arises  in  connection  with  sarcoma,  tuberculosis,  gumma, 
and  cysts  of  the  bone ;  indeed,  exploratory  exposures  and  substantia- 
tory  microscopical  examination  may  be  necessary  for  the  purpose  of 
arriving  at  a  conclusion. 

Myelogenous  and  periosteal  sarcomata  bear  a  resemblance  to  chronic 
osteomyelitis.  The  latter  is  commonly  situated  near  the  joints,  begins 
with  gradual  thickening,  and  suddenly  develops  inflammation.  When 
this  occurs  the  doubt  should  be  removed ;  however,  in  some  instances, 
the  inflamed  thickened  bone  area  contains  chiefly  granulation  tissue 
surrounded  by  a  thin  wall  of  bone,  in  which  event  the  diagnosis  must 
rest  on  the  bacterioscopic  findings  (Jordan^*).  Periosteal  thickening, 
due  to  the  residual  detritus  of  old  bone  inflammations,  may  stand  in 
a  causative  relationship  to  periosteal  sarcoma.  Exposure  uncovers 
small,  dark,  granulations,  pus  foci  and  sequestra. 

Bone  tuberculosis  is  most  likely  to  be  confused  with  chronic  epiphy- 
seal foci,  especially  when  complicated  by  serous  exudate  into  the  joint. 
A  decision  is  usually  not  arrived  at  until  spontaneous  rupture  occurs, 
or  surgical  exposure  is  made.  In  the  former  instance,  the  character- 
istic appearance  of  the  fistulae  is  helpful.  In  the  pyogenic  form  the 
pus  is  thick  and  slimy  —  not  cheesy,  and  the  sequestra  are  irregularly 
scalloped  —  not  round  as  they  are  with  tuberculosis. 


302  INFECTIONS  OF  WOUNDS 

Luetic  hone  thickening  simulates  the  chronic  sclerotic  (uon-suppura- 
tive)  form  of  infection,  especially  when  the  latter  is  not  preceded  by 
an  acute  stage.  Luetic  lesions  possess  certain  characteristics  discover- 
able by  X-ray  examination. 

Bone  cysts  resemble  encapsulated  serous  abscesses.  In  the  absence 
of  differential  diagnostic  data,  exploratory  puncture  or  incision,  and 
microscopical  examination  of  the  material  thus  obtained  should  re- 
veal the  character  of  the  lesion. 

The  treatment  of  chronic  purulent  osteomyelitis  consists  in 
the  removal  of  the  sequestrum  and  emptying  of  the  purulent 
FOCI,  which,  when  the  lesion  is  central,  demands  the  gouging  out  of  the 
enniantUng  cortex  (necrotomy).  Complete  separation  of  a  large  total 
sequestrum  and  the  reproduction  of  a  firm  involucrum  occurs  in 
about  six  months,  following  the  disease. 

After  V.  Esmarch  exsanguination,  the  bone  is  longitudinally  ex- 
posed to  the  extent  of  the  thickening ;  the  periosteum  is  split  to  the 
same  degree,  separated  from  the  involucrum,  a  gutter  cut  into  the 
latter  (p.  00)  ;  and  the  sequestrum  removed.  The  exuberant  granu- 
lation tissue,  thickened  pus,  and  pyogenic  membrane  are  removed  by 
means  of  spoons  and  wipes;  and  the  sharp  irregular  borders  of  the 
bone  cavity  are  leveled  with  a  straight  chisel.  Necrotic  bone  tissue 
should  be  thoroughly  removed  and,  if  necessary,  the  epiphysis  and 
articular  cartilages  attacked;  however,  unnecessary  trauma  to  these 
important  structures  should  be  avoided  for  obvious  reasons.  The  oper- 
ative treatment  is  more  extensively  taken  up  in  part  lY. 

Healing  takes  place  by  granulation,  the  cavity  being  lightly  tam- 
poned while  repair,  which  is  protracted,  takes  place.  Frequently 
fistulous  openings  remain  at  the  site  of  the  metaphysis ;  these .  may 
have  to  be  repeatedly  curetted  before  complete  repair  is  established. 

Closure  of  deep  hone  cavities,  situated  near  the  joints,  may  be  at- 
tained b}'  the  use  of  pediculatecl  sliin  flaps — after  granulation  has 
been  established.  Better  still,  the  original  method  of  approach  may 
be  executed  so  that  the  removal  of  the  tampon,  inserted  immediately 
after  the  operation,  may  be  followed  by  approximation  of  the  skin  by 
means  of  nails,  adhesive  plaster  strips,  etc. 

Osteoplastic  necrotomy  (Oilier*^),  which  consists  of  using  the  skin, 
together  with  a  portion  of  the  periosteum  and  involucrum,  for  the 
purpose  of  filling  the  defect,  is  of  doubtful  utility.  The  flap  favors  re- 
tention of  purulent  disintegration,  at  times  undergoes  degeneration 
itself,  and  does  not  shorten  the  period  of  repair. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     303 

The  introduction  into  the  resultant  bone  cavitj'  of  various  medi- 
cated, soft,  moldable  mixtures  is  of  value.  Of  these,  a  mixture  of 
sixty  parts  of  iodoform  and  forty  parts  spermaceti  and  oil  of  sesame 
(Mosetig'-Moorhof*')  is  most  serviceable.  The  cavity  is  first  dried 
■with  the  hot  air  blast ;  for  this  purpose,  Lexer^^  uses  a  mixture  of 
sterile  wax  which  he  firmly  presses  into  the  walls  of  the  cavity  until 
bleeding  ceases.  The  iodoform  plug  does  not  act  as  a  foreign  body; 
it  is  gradually  absorbed  and  ultimatelj^  replaced  by  connective  or 
bone  tissue.  The  supei-ficial  wound  may  be  sutured,  without  drain- 
age, over  defects  treated  in  this  way.  The  introduction  of  fresh  bone 
fragments,  together  with  their  adherent  periosteum  (v.  Mangold*^), 
and  of  fat  grafts  (^Makkas*^)  has  been  followed  by  good  results. 

The  sequelae  of  purulent  osteomyelitis  are  many,  and  present  widely 
varied  pictures. 

Spontaneous  complete  fracture  and  infraction  occur  at  the  weakest 
portion  of  the  bone,  usually  at  the  line  of  demarcation  of  the  inflam- 
matory process  where  the  involucrum  is  thin,  and  at  times  at  the  point 
where  the  sequestrum  is  widest.  The  occurrence  of  fracture  calls  for 
immediate  necrotomy,  followed  by  immobilization.  Repair  is  slow 
and  permanent.     Non-union  is  not  exceptional. 

Pathological  luxation  occurs  most  frequently  at  the  hip,  and  sub- 
luxations are  common  at  the  knee  joint.  Destruction  luxation  is  a 
term  used  to  designate  solution  of  contiguity  of  joint  surfaces,  due  to 
purulent  degeneration.  "When  this  is  due  to  stretching  of  the  joint 
capsule,  with  effusion,  the  term  distention  luxation  is  used.  The 
divergence  in  the  prognosis  of  the  two  conditions  makes  the  differen- 
tial diagnosis  an  important  matter.  Separation  of  the  acetabulum 
from  the  ilium  simulates  dislocation  of  the  head  of  the  femur  (Fran- 
genheim^'^).  The  condition  is  rare,  but  should  be  recognized  with  the 
aid  of  a  Rontgenogram. 

Interference  with  the  development  of  the  infected  bones  and  those 
contiguous  to  them  leads  to  a  variety  of  deformities  (Oilier**  and 
others).  Shortening  follows  destruction  of  the  epiphysis,  as  it  is  not 
reproduced.  Diaphyseal  and  metaphyseal  foci  maintain  persistent 
irritation,  causing  an  overproduction  of  new  bone  and  consequent 
lengthening.  Both  these  phenomena  have  been  observed  experimen- 
tally, and  vary  with  the  location  of  the  pathological  focus  (Lexer*®). 
In  the  forearm  and  leg,  the  process  provokes  (by  shortening  or  length- 
ening) various  deformities  such  as  pes  valgus,  manus  radioflexa,  genu 
valgum,  varum,  etc.,  which  are  attended  with  dissociation  of  joint 


304 


INFECTIONS  OF  WOUNDS 


surfaces  and  bending  of  the  more  rapidly  growing  (pathological  or 
normal)  bone  (Fig.  132).  Lengthening  of  the  normal  bone  of  a  limb 
is  ascribed  to  the  hyperemia  provoked  by  the  inflammation;  so  the 
femur  elongates  when  the  tibia  is  affected  and  vice  versa;  and  when 
the  forearm  is  affected, 
the  humerus  is  length- 
ened. In  this  way 
shortening  of  the  entire 
limb  is  obviated ;  indeed, 
Oilier'*^  holds  that  every 
shrinking  of  a  sector  of 
bone  is  compensated  for 
by  enlargement  of  its 
contiguous  portion 

(Regnault^^). 

Joint  complications 
result  in  contractual  de- 
formities and  fibrous 
ankjiosis. 

Recurrent  osteomyeli- 
tis occurs  in  the  adult, 
and  develops  after  a 
suppurative  osteomyeli- 
tis has  been  apparently 
healed  for  a  year  or 
more.  The  new  activ- 
ity may  occur  at  the  site 
of  the  old  lesion  or  in  a 
new  situation.  The 
causative  factor  is  either 
a  reinvasion  of  latent 
spores,  or  a  renewed 
hematogenous  infection 
w^hich     settles     in     the 

bone ;  both  are  possible ;  the  scar  tissue  at  the  site  of  the  old  process  is 
undoubtedly  frequently  the  habitat  of  latent  bacteria,  and  there  is  no 
good  reason  why  it  should  not  at  any  time  be  invaded  by  a  fresh 
hematogenous  focus ;  again,  one  can  never  be  certain  that  the  bone 
may  not  have  been,  during  childhood,  the  residence  of  an  infectious 
inflammatory  process  which  healed  without  symptoms  (Garre^^). 


Fig.  132. —  Eadioflexion  of  the  Hand  Fol- 
lowing Destruction  of  the  Lower  Epi- 
physis BY  Suppurative  Osteomyelitis. 


PYOGENIC  INP^ECTIONS  OF  VARIOUS  TISSUES      305 

A  definite  hacterial  classification  of  hematogenous  purulent  osteo- 
myelitis is  impossible,  since  the  differences  in  the  clinical  manifesta- 
tions are  not  sufficiently  marked  for  the  purpose. 

Streptococci  cause  cortical  and  central  lesions  of  the  metaphyses 
with  suppurative  arthritis.  In  children  they  often  give  rise  to  medul- 
lary phlegmon  with  epiphyseal  separation  and  extensive  necrosis. 
The  coccus  is  also  responsible  for  ostitis  alhuminosa  and  thickening, 
and  degeneration  of  flat  hones.  Streptococcus  pus  is  fluid,  thin, 
greenish  in  color,  and  abundant.  Mixed  infections  with  staphylococci 
are  common  and  follow  a  stormy  course.  Klemm  V^  claim  that  strep- 
tococcus phlegmon  of  the  medulla  does  not  occur  is  disputed  by 
Lexer,'*^  who  has  observed  twelve  such  cases. 

Pneumococcus  foci  are  rare,  usuall}'  located  at  the  articular  ends  of 
bones,  and  frequently  give  rise  to  suppuration  in  the  contiguous  joints. 
They  rarely  occur  in  the  medulla  of  bones.  Periosteal  and  cortical 
lesions  complicate  pneumonitis  in  both  infants  and  adults,  and  at 
times  occur  at  the  site  of  an  accidentalh'  produced  fracture  (Lexer*^). 

Gonorrheal  osteomyelitis  is  rare.  However,  it  has  been  observed  in 
the  femur  b}'  Holmberg^^ ;  in  the  humerus  by  Ullman^^ ;  in  the  tibia 
by  HejTnann^'* ;  and,  in  a  case  of  costal  perichondritis,  by  Finger.^^ 

The  'bacterium  coll  communis  has  been  found  in  several  instances 
(Klemm^^)  in  conjunction  with  the  bacillus  typhosus  and  staphylo- 
coccus. Its  presence  is  indicated  by  the  characteristic  fecal  odor  of 
the  pus. 

The  'bacillus  pneumoniae  of  Ffiedlander  was  found  by  Schlagen- 
haufer°®  in  a  case  of  extensive  osteomyelitis  of  the  femur  in  an  adult. 
Actinomycosis  at  times  attacks  the  bone  in  the  form  of  hematogenous 
foci  ("Wrede^").  "Wyssokowicz^*  found  an  atiaero&ic  bacillus  (bacillus 
halosepticus)  in  a  case  of  putrid  osteomyelitis  of  the  tibia. 

Osteomyelitis  typhosa,  because  of  its  connection  with  tj^phoid  fever, 
demands  special  clinical  consideration.  It  develops  as  the  result  of 
the  deposit  of  typhoid  bacilli  in  the  bone  marrow,  and  usually  becomes 
manifest  in  the  third  or  fourth  week  of  the  disease;  but  it  may 
remain  quiescent  and  suddenly  be  provoked  into  pathogenesis  after  a 
lapse  of  many  years.  The  bacillus,  frequently  associated  with  pyo- 
genic excitants,  gains  access  to  the  blood  current  from  ulcers  in  the 
gut.  Clinically,  infection  begins  with  renewed  fever  and  local  pain, 
often  follows  trauma,  and  is  attended  by  an  inflammatory  infiltration 
of  the  bone.  The  abscess  (which  usually  forms),  when  due  to  tjT^hoid 
bacilli  alone,  contains  a  yellowish  brown,  rust  colored  fluid  called 


306  INFECTIONS  OF  WOUNDS 

typhoid  pus,  which  may  be  sterile.  When  mixed  infection  is  added, 
the  fluid  does  not  differ  in  character  from  that  formed  in  response  to 
pyogenic  invasion.  The  breaking  down  of  the  abscess  leads  to  the 
prolonged  discharge  of  pus,  which  is  maintained  by  the  presence  of 
small  foci  of  granulation  tissue  and  necrotic  hone  that  communicate 
with  the  surface  by  means  of  fistulous  tracts  resembling  those  common 
to  tuberculosis.  The  lesions  are  most  frequently  located  in  the  car- 
tilages of  the  rihs  (Fig.  133)  close  to  the  costal  margin  (chondritis  and 
perichondritis),  or  in  the  osseous  portion  of  the  rihs  themselves,  and 
are  characterized  by  the  formation  of  small  sequestra  embedded  in 
granulation  tissue  and  surrounded  by  a  thin  periosteal  shell.  Cortical 
and  central  foci  are  often  found  in  the  tihia,  and  at  times,  in  the  pelvis, 
bones  of  the  skull,  sternum,  clavicle,  humerus,  femur,  and  in  the 
bodies  of  the  vertebrae  (spondylitis  typhosa).  After  a  short  acute 
period,  the  course  of  the  infection  becomes  chronic.  Multiple  foci  are 
not  uncommon.  The  inflammation  has  a 
tendency  to  remain  insular  and  is  not  provo- 
cative of  marked  reactive  bone  genesis.  The 
picture  of  acute  suppurative  osteomyelitis 
attends  mixed  infections,  as  well  as  staphy-  ^^^^  133,  —  Typhoid 
lococcus   or  streptococcus  invasion   of  bone  Focus    in    a    Costal 

,      .        ,      ^     '  1  £  Cartilage. 

during  typhoid  lever. 

In  cases  of  typhoid  fever,  Eberth's  bacillus  is  found  in  bones  as 
regularly,  if  not  in  as  large  numbers,  as  in  the  spleen.  The  bacilli 
retain  procreative  viability  for  many  years  after  recovery  from  the 
disease  and  may  give  rise  to  a  mild  but  generally  distributed  patho- 
genesis in  the  forms  of  periosteal  hyperplasia  and  caries  of  the  bones. 
This  explains  the  development  of  typhoid  inflammation  following 
trauma,  and  also  the  occurrence  of  lesions  in  bones  of  patients  whose 
medullary  substance  has  become  relatively  nonresistant  as  the  outcome 
of  typhoid  fever. 

Secondary  purulent  osteomyelitis  occurs  as  an  immediate  or  remote 
complication  of  all  acute  infectious  diseases. 

First,  as  the  result  of  the  direct  invasion  of  the  specific  excitants  of 
typhoid  fever,  pneumonitis,  etc. ;  and  second,  because  infectious  dis- 
eases create  ports  of  entrance  for  the  ordinary  pus  excitants,  or  because 
the  bone  marrow  is  already  enfeebled  as  the  outcome  of  its  efforts  to 
overcome  the  general  infection,  and  thus  is  made  susceptible  to  the 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     307 

pathogenesis  of  additional  aggressors  (typhoid,  scarlatina,  diphtheria, 
influenza,  measles,  variola,  etc.)- 

PhospJiorus  necrosis  may  also  be  classified  as  secondary,  but  it  is 
not  a  clearly  defined  pathogenous  osteomyelitis.  P&isoning  with 
phosphorus,  as  it  occurs  in  persons  who  inhale  its  fumes  (especially 
match  workers),  leads  to  pathological  changes  in  the  osseous  system 
which  on  autopsy  arc  found  to  be  a  form  of  ossification  (phosphorus 


Fig.  134. —  Phosphorus  Xecrosis  of  the  ]\Iaxdible  After  Haeckel. 
Eemoved  from   a   woman   twenty-five  years  of  age.     At   Tc,  beginning   line  of 
demarcation ;  at  Z,  a  cloaca  in  the  depth.s  of  which  a  cortical  sequestrum  may  be 
seen.     Osteophytes  cover  the  surface  of  the  bone. 

periostitis  and  sclerosis),  yet,  clinically,  would  seem  to  be  an  abnormal 
softening  and  friabilitj^  of  the  bone.  HaeckeP^  reports  a  case  that 
sustained  thirteen  fractures  in  sixteen  years.  The  exact  nature  of  the 
process  is  not  known ;  its  occurrence  in  the  lower  jaw  is  no  doubt 
favored  b}'  contact  with  the  warm  fumes. 

Experimentally,  Wegner^'''  succeeded  in  producing  an  osteosclerosis 
in  young  animals  by  persistently  feeding  them  small  quantities  of 


b 


308  INFECTIONS  OF  WOUNDS 

phosphorus ;  on  the  other  hand,  the  direct  application  of  the  agent  to 
the  exposed  bone  was  barren  of  result  (v.  Steubenrauch*^^). 

The  clinical  manifestations  of  the  disease,  best  observed  in  connec- 
tion with  its  attack  upon  the  lower  jaw,  were  first  described  by 
Lorinzer  in  1845,  as  follows : 

"The  advent  of  the  process  is  insidious,  and  is  characterized  either 
by  increasing  friability  or  by  thickening  and  sclerosis  of  the  inferior 
maxilla.  The  actual  signs  of  the  disease,  which  may  be  properly 
regarded  as  a  secondary  purulent  or  fetid  osteomyelitis  of  a  hone  pre- 
viously affected,  begin  with  inflammation  of  the  gums  and  periosteum, 
which  is  ascribable  to  the  entrance  of  the  excitants  of  pus  and  putre- 
scence into  carious  teeth,  ulcers,  and  injuries  of  the  buccal  cavity. 
The  gums  become  swollen  and  painful,  and  the  teeth  loosen,  though 
extraction  is  not  —  as  with  ordinary  periostitis  alveolaris  —  followed 
by  relief.  Pain  and  swelling  increase,  the  floor  of  the  mouth  and  the 
cheek  become  infiltrated,  soften  and  develop  fistulous  openings  which 
discharge  foul  smelling  pus.  More  teeth  loosen,  and  the  gums  and 
periosteum  are  raised  from  the  bone,  denuding  its  surface.  The  bone 
becomes  necrotic,  often  entirely  so  in  six  months,  the  remaining  peri- 
osteum in  the  meantime  furnishing  a  massive  involucrum,  and  the 
necrotized  bone  goes  on  (in  two  or  three  years)  to  sequestration." 

Healing  follows  expulsion  of  the  sequestrum.  However,  the  occur- 
ren.ce  of  ankylosis,  digestive  disturbances  from  the  ingestion  of  fetid 
material,  malnutrition,  pain,  febrile  movement,  marasmus  and  com- 
plications of  many  kinds,  meningitis  by  extension,  general  infection, 
and  pneumonitis  produce  fatal  results  in  aiout  fifty  per  cent  of  the 
cases. 

The  lower  jaw  is  involved  nine  times  as  often  as  the  upper,  and  is 
also  necrosed  much  more  frequently. 

The  treatment  of  phosphorus  necrosis  relates  primarily  to  its  pre- 
vention, which  consists  of  thorough  ventilation  of  the  work  shop, 
frequent  cleansing  of  the  hands,  refraining  from  eating  and  drinking 
in  the  shop,  and  the  hygiene  of  the  mouth.  The  local  lesion  must  be 
attacked  by  operative  measures,  complete  subperiosteal  resection  of  the 
diseased  bone  must  be  promptly  executed  (Riedel,^^  HaeckeP^).  The 
periosteum  in  this  location  has  great  regenerative  capacity,  so  that 
very  extensive  resection  of  bone  is  followed  by  its  restoration,  the 
resumption  of  cosmetic  outline  and  return  of  function. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     300 

F.    PYOGENIC  INFECTIONS  OF  JOINTS 

Pyogenic  infection  invades  joints  directly  througli  a  solution  of 
continuity  of  the  overlying  parts,  by  means  of  gunshot,  incised,  and 
punctured  wounds;  the  introduction  of  foreign  bodies  (needles,  nails, 
glass  and  steel  fragments,  etc.)  ;  and  through  compound  dislocations 
and  fractures  extending  into  the  articular  surfaces.  Indirectly,  joint 
infections  are  the  result  of  contiguous  phlegmon,  erysipelas,  acute  and 
chronic  osteomyelitis,  and,  at  times,  the  fistulae  of  tuberculous  joints 
form  viaducts  through  which  pyogenic  bacteria  gain  access  to  joints. 

Hematogenous  pyogenic  joint  inflammations  follow  the  bacterial 
invasion  of  the  capillaries  of  the  synovial  membrane  in  the  course  of 
many  diseases,  especially  if  the  local  resistance  of  the  joint  is  reduced 
by  trauma.  In  this  way,  serous  exudation  complicates  endocarditis 
and  acute  articular  rheumatism,  though  the  causative  relationship  of 
the  latter  is,  as  yet,  not  positively  proved.  On  the  other  hand,  the 
development  of  purulent  exudates  in  joints  is  clearly  dependent  upon 
the  presence  of  a  pyogenic  process  elsewhere  in  the  body  and  a 
coexisting  bacteriemia. 

Serous  and  purulent  joint  inflammations  frequently  complicate 
acute  infectious  diseases,  which  either  create  ports  of  entrance  for 
pyogenic  excitants  (diphtheria,  scarlatina,  measles,  etc.)  or  whose 
specific  aggressors  alone  are  causative  factors  in  this  connection 
(typhoid  fever,  pneumonitis,  gonorrhea,  infectious  meningitis,  etc.). 

For  this  reason,  the  bacterial  excitants  of  joint  suppuration  are  not 
only  staphylococci  and  streptococci  and  the  rarer  forms  of  pus  organ- 
ism, but  the  lesions  are  also  produced  by  pneumonitis  bacilli,  meningo- 
cocci, etc. 

The  synovial  memhrane,  which  consists  of  two  layers  —  an  inner 
stratum  synoviale  and  an  outer  stratum,  fihrosum,  covers  the  entire 
joint  surfaces  and  the  epiphyseal  cartilages.  Its  inner  surface  is  not 
covered  by  epithelium  nor  endothelium,  but  is  clothed  by  a  thin  laj'er 
of  connective  tissue  from  which  are  projected  slender,  threadlike  or 
leaflike  fsitty  villosities.  S^^lovial  membranes  and  their  villi  are 
richly  supplied  wdth  blood  vessels  and  capillaries  extending  to  the 
stratum  sjmoviale;  they  contain  an  abundant  network  of  lymph  ves- 
sels which,  unlike  those  of  the  larger  serous  cavities,  do  not  communi- 
cate directly  with  the  joints. 

Pathogenic  excitants  gain  access  to  synovial  membranes  through 
traumatized  capillaries ;  or  enter  with  the  exudate  of  a  ruptured  bone 
lesion,  are  mixed  with  the  sjTiovial  fluid  and  disseminated  over  the 


310  INFECTIONS  OF  WOUNDS 

entire  joint  surface.  In  either  event,  the  response  to  the  invasion 
takes  on  the  form  of  an  inflammatory  process  in  the  synovia  and  in  the 
joint  capsule.  The  meager  bactericidal  capacity  of  the  synovia  is 
explained  on  the  ground  that  the  inflammatory  process  is  promptly 
isolated,  and  the  excitants  are  thus  made  inaccessible  to  the  combative 
forces  of  the  general  circulation  (NotzeP^). 

Inflammations  may  be  divided  into  two  general  forms :  Synovitis, 
when  only  the  sjaiovia  is  involved,  and  arthritis,  when  the  entire  joint 
is  affected.  The  lesion  is  attended  by  serous,  fihri)ious,  or  purulent 
exudation,  to  which  may  be  added  the  putrid  form  —  when  putrefac- 
tive excitants  are  also  present.  The  various  kinds  of  exudates  may 
exist  in  combination. 

Serous  and  Serofibrinous  Synovitis.—  This  condition  follows  injuries 
that  open  the  joint;  occurs  from  extension  of  inflammation  from 
epiphyseal  foci;  is  a  not  infrequent  complication  in  acute  infectious 
diseases;  and  is  a  part  of  general  pyogenic  infection  (bacteriemia). 

The  acute  form  usually  develops  simultaneously  in  more  than  one 
joint,  and  is  manifested  by  pain,  tension,  interference  with  or  loss  of 
function,  fever,  and  more  or  less  severe  constitutional  disturbances. 
The  overlying  skin  is  usually  hot  and  slightly  reddened. 

"When  serous  transudation  is  excessive  in  amount,  the  joint  capsule 
and  the  adjacent  bursae  become  distended,  and  protrude  at  points  of 
lessened  resistance  (such  as  the  sides  of  the  patellar  ligament)  M-here 
fluctuation  usually  may  be  elicited.  The  normal  contour  of  the 
affected  joint  is  obliterated  and  its  outline  conforms  to  that  of  the 
distended  capsule. 

When  fluid  effusion  is  moderate  in  amount,  the  capsule  is  heavily 
infiltrated  and  the  s;>Tiovia  covered  with  fibrinous  deposits ;  palpation 
discloses  the  thickened  capsule,  and  slight  movement  of  the  joint  or 
pressure  with  the  fingers  elicits  friction.  As  the  result  of  edematous 
infiltration  of  the  peri-  and  para-articular  tissues,  the  outline  of  the 
joint  is  less  clearly  defined  than  is  normal  (especially  in  phlegmonous 
gonococcus  arthritis). 

The  course  of  serous  inflammation  is  not  a  menacing  one  and  as  a 
rule  complete  restitution  to  the  normal  obtains.  Repetition  of  exuda- 
tion provokes  a  chronic  condition  of  hydrarthrosis  and  villous  hyper- 
plasia, with  consequent  stretching  of  the  capsule  which  may  lead  to 
malposition  of  the  joint  surfaces  or  unnatural  motility  of  the  parts. 
Pathological  partial  or  complete  dislocations   (distention  luxations) 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      311 

occur  without  alteration  in  the  bones  or  articular  cartilages  (especially 
following  typhoid  fever,  scarlatina,  etc.)- 

Severe  inflammation  of  the  capsule  is  followed  by  shrinTiing  and 
permanent  limitation  of  motion,  due  to  fibrinous  adhesions  and  con- 
nective tissue  hyperplasia  (especially  in  gonorrheal  arthritis). 

The  serous  exudate  is  yellowdsh  in  color,  slightly  turbid,  contains  a 
moderate  number  of  pus  cells,  and  is  differentiated  from  s}^lovial  fluid 
by  its  lessened  mucin  and  increased  albumin  content.  The  fibrinous 
exudate  consists  of  fluid  similar  to  that  of  serous  exudate,  but  it  is 
rich  in  fibrin  content  which,  in  acute  inflammation,  is  flocculent  or  is 
deposited  upon  the  thickened  S3^lOvia  and  its  villi;  and,  in  chronic 
inflammations,  forms  a  fibrinous  lining  within  the  joint  membrane  that 
ultimately  becomes  organized  into  connective  tissue,  and  is  responsible 
for  the  adhesion  of  adjacent  articular  surfaces  and  more  or  less 
ankylosis. 

The  treatment  of  serous  and  serofibrinous  sjTiovitis  in  acute  cases 
consists  of  aspiration  and  immohilization.  In  the  chronic  and  recur- 
rent forms,  aspiration  is  supplemented  by  lavage  with  carbolic  acid 
solution  (1-2  per  cent)  or  boric  acid.  Early  massage  and  carefully 
executed  passive  motion  are  indicated  in  cases  showing  a  tendency  to 
ankylosis.  Artificial  hyperemia  provoked  by  the  application  of  coun- 
terirritants  (iodin,  etc.),  the  use  of  hot  air  (Tyrnauer  apparatus), 
and  the  judicious  employment  of  Bier's  constriction  method,  serve  a 
useful  purpose  w^hen  thickening  and  exudation  are  persistently 
maintained. 

Arthritis. —  Purulent  joint  inflammations  (joint  empyemata)  are 
both  superficial  and  deep,  involving  the  synovia  alone  or  the  entire 
joint  structure  (spiovitis  and  arthritis  (panarthritis)  acuta  puru- 
lenta). 

Superficial  joint  suppuration  (synovitis  purulenta)  is  the  less 
destructive  form.  The  synovia  is  red,  swollen,  and  exudes  slimy  pus 
mixed  with  fibrin  fiocculi.  As  only  the  superficial  structures  of  the 
capsule  are  involved,  early  measures  of  relief  are  not  infrequently 
followed  by  complete  restitutio'n  to  the  normal.  If  left  to  itself,  the 
process  invariably  results  in  permanent  deformity  and  loss  of  function. 

The  purulent  form  of  synovitis  complicates  acute  infectious  diseases ; 
occurs  from  the  extension  of  purulent  epiphyseal  foci,  and  is  a  part 
of  general  pyogenic  infection  more  frequently  than  are  the  serous  and 
serofibrinous  forms.  The  bacterial  excitants  are  usually  staphylo-  and 
streptococci,  and  occasionally  pneumococci.     The  latter  two  cocci  are 


312       .  INFECTIONS  OF  WOUNDS 

not  uncommonly  the  cause  of  catarrhal  joint  infections,  secondary  to 
osteomyelitis  in  children. 

The  recognition  of  synovitis  purulenta  is  based  on  the  general  symp- 
toms of  pyogenic  infection,  together  with  local  swelling ;  loss  of  con- 
tour of  the  joint,  due  to  inflammatory  edema ;  loss  of  function ;  severe 
pain  and  exquisite  tenderness.  The  local  s;yTiiptoms  simulate  gonor- 
rheal arthritis. 

The  treatment  consists  of  early,  free  incision  followed  by  immediate 
light  tamponade,  and  later  drainage,  together  with  imm.ohilization. 
In  some  instances,  recession  of  the  process  follows  simple  aspiration 
(strepto-  and  pneumococcus  inflammations).  If  the  joint  involve- 
ment is  due  to  extension  from  a  bone  lesion,  this  must,  of  course,  be 
freely  opened  and  cleansed.  After  subsidence  of  the  acute  symptoms, 
carefully  executed  passive  and  active  motion  may  be  employed.  When 
these  measures  are  begun  too  early,  the  occurrence  of  local  and  general 
complications  is  favored. 

Deep  joint  suppuration  (arthritis  purulenta)  is  not  restricted  to 
the  synovia,  but  also  attacks  the  peri-  and  para-articular  tissues,  or 
ruptures  into  the  surrounding  parts,  causing  phlegmonous  inflamma- 
tions and  abscess  formation  in  the  loose  connective  tissue  between  the 
muscles  and  planes  of  fascia,  and  ultimately  leads  to  destruction  of  the 
joint  capsule  and  contiguous  articular  cartilages. 

This  severe  form  of  the  affliction  is  the  outcome  of  staphylo-  and 
streptococcus  invasion.  It  follows  all  kinds  of  trauma,  the  intracap- 
sular rupture  of  purulent  foci  located  in  bone  areas  contiguous  to  the 
joint,  and  is  a  frequent  complication  of  pyogenic  general  infection. 
A  primary  pyo-arthritis  may  be  the  initial  lesion  of  bacteriemia. 

Recognition  of  the  process  rests  (beyond  the  usual  picture  of  joint 
inflammations)  upon  two  distinctive  features:  The  development  of 
phlegmonous  inflammation  in  the  region  of  the  joint  —  indicating 
rupture  of  the  capsule ;  and  upon  crepitation  or  malposition  of  the 
contiguity  of  the  bones  —  indicating  extensive  destruction  of  the 
capsule,  the  ligaments,  and  the  articular  cartilages. 

The  treatment  is  directed  toward  drainage  of  the  pus  from  the 
joint  and  the  para-articular  abscesses.  For  this  purpose,  the  soft 
parts  are  freely  incised  (arthroiomy),  the  capsule  opened  and  the 
cavity  drained.  In  severe  cases,  the  joint  should  be  at  once  widely 
exposed  by  an  incision  which  permits  of  immediate  arthrectomy 
(Part  IV).  When  these  measures  are  not  followed  by  arrest  of  the 
process,  complete  resection  of  the  joint  should  be  employed,  thus  obvi- 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      313 

ating  (if  possible)  the  necessity  for  amputation.  In  a  certain  number 
of  cases  the  extent  of  the  phlegmonous  inflammation,  secondary  bone 
invasion,  and  the  menacing  character  of  the  constitutional  symptoms 
call  for  amputation  of  the  part. 


Fig.   135. —  A,  Osteomyelitis  Femoris;   Ankylosis  Ossea;   Lateral  Disloca- 
tion.    B,  Preparation  of  Amputated  Limb, 

When  the  joint  survives  the  destructive  action  of  the  inflammation 
(which  is  not  uncommon),  meehano-therapy,  artificial  hj'peremia, 
Tyrnauer  hot  air,  baths,  massage,  and  passive  motion  may  be  employed. 

The  sequelae  of  joint  inflammations  are  mainly  ankylosis,  malposi- 
tion of  articular  surfaces,  and  trophic  disturhances. 


314 


INFECTIONS  OF  WOUNDS 


Ankylosis  is  caused  by  contraction  of  the  capsule,  and  by  prolifera- 
tion of  connective  tissue  into  the  joint  and  bones. 

Disturbances  of  joint  motility  due  to  contraction  of  the  capsule, 
follow  all  inflarimatory  processes  that  infiltrate  the  entire  capsule  and 
the  peri-  and  para-articular  soft  parts.  Fibrinous  inflammation 
causes  ankylosis  by  the  deposit  of  fibrinous  exudate  upon  the  apposed 
synovial  covering  of  joint  surfaces,  which  adhere  to  each  other,  become 
organized,  form  scar  tissue,  and  firmly  coalesce.  To  this  is  added  a 
layer  of  connective  tissue,  which  proliferates  from  the  capsule,  extends 


Fig.  136. —  Osseous  Axktlosis  of  Knee  Following  Arthritis  Purulenta 


between  the  layers  of  scar  tissue  and  merges  with  it  {anki/losis  fihrosa 
intercartilagi^wsa) .  In  the  severe,  deep  form  of  infection,  the  cartilage 
exfoliates  or  becomes  absorbed,  and  repair  is  attended  with  connective 
tissue  h^'perplasia  followed  by  osteogenic  obliteration  of  the  joint 
surfaces  (ankylosis  fibrosa  ossea,  and  ankylosis  ossea,  or  synostose). 

During  the  active  inflammatory  stage  of  the  disease,  the  part  should 
be  immobilized  in  a  posture  best  conserving  its  usefulness  when  the 
extent  of  the  sequential  ankylosis  is  attained ;  for  instance,  in  infec- 
tions of  the  wrist  and  elbow  joints,  the  forearm  should  be  semiflexed 
and  placed  in  a  position  midway  between  pronation  and  supination ; 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES     315 

in  knee  joint  inflammations,  the  leg  should  be  fully  extended ;  and  in 
coxitis,  the  thigh  should  be  abducted. 

The  treatment  of  ankylosis  consists  of  passive  motion,  massage,  and 
baths ;  though  the  employment  of  these  measures  should  be  postponed 
until  the  active  process  has  subsided. 

Malpositons  become  manifest  early  in  the  course  of  joint  inflamma- 
tions. They  are  the  result  of  the  effort  on  the  part  of  the  patient  to 
place  the  inflamed  surfaces  in  a  position  affording  relief  from  pain. 

This  posture  corresponds  to  the  one  which  permits  of  the  greatest 
amount  of  distention  Cf  the  capsule  with  fluid  exudate  (see  articular 
tuberculosis). 

These  malpositions,  called  arthrogenous  contractures,  are  primarily 
due  to  reflex  muscular  tension  and  may  be  overcome  by  the  production 
of  the  narcotic  state;  after  a  time,  however,  the  proliferation  of  con- 
nective tissue  produces  permanent  malposition  and  impairment  of 
motion  —  the  result  of  the  coadhesion  of  the  structures  of  the  joint. 
Arthrogenous  contractures  and  ankjdosis  cause  fixation  of  the  elbow 
and  wrist  in  pronation,  the  knee  joint  in  flexion,  and  the  hip  joint  in 
flexion  and  adduction  with  the  foot  tending  toward  plantar  flexion. 

Contractures  are  not  infrequently  attended  with  pathological  dislo- 
cations, the  result  of  relaxation  and  of  stretching  of  the  capsule  from 
effusion  (typhoid  fever,  scarlatina,  and  variola  —  distention  luxation), 
or  are  caused  by  the  destruction  of  articular  surfaces  {destruction 
luxation)  by  virulent  pyogenic  processes.  In  the  knee  joint  the 
deformity  often  takes  on  the  form  of  a  subluxation. 

The  treatment  of  contractures  during  the  inflammations  consists  of 
gentle  corrective  ex*^ns^ion  by  means  of  Buck's  apparatus,  counter 
weights,  etc.,  made  to  meet  the  particular  indication.  Older  contrac- 
tures with  fihrous  ankylosis  may  be  stretched  or  torn  asunder  under 
narcosis  {hrisemerit  force),  the  malposition  corrected  and  the  part 
immobilized  in  gj'psum  for  from  two  to  three  weeks,  followed 
by  massage,  passive  motion,  etc.  Contractures  with  hony  ankylosis 
may  be  corrected  by  resection  of  the  articular  surfaces,  the  technic  of 
which  is  executed  in  a  manner  suitable  to  the  problem  under  consider- 
ation. Pathological  dislocations  usually  require  complete  excision. 
When  conditions  permit,  resection  should  be  followed  by  the  inter- 
position between  the  bones  of  either  pediculated  or  free  muscle,  perio- 
steal or  fat-fascial  flaps,  or  of  free  cartilaginous  disks,  with  the  view 
of  affording  more  or  less  motion. 

Trophic  disturbances  are  manifested  b}'  muscular  atroph]/,  especially 


316  INFECTIONS  OF  WOUNDS 

of  the  extensor  groups,  which  permits  contracture  of  the  opposing 
flexor  muscles.  This  is  explained  partly  on  the  basis  of  disuse  and  in 
part  is  accounted  for  by  the  Paget-Vulpian  theory  of  reflex  atrophy 
(Hoffa^^),  namely,  that  the  irritation  of  the  nerve  filaments  in  the 
joint  is  conveyed  to  the  spinal  centers  of  the  muscles,  causing  a  simple 
muscular  atrophy. 

The  treatment  consists  of  mechanical  and  thermal  therapy. 

The  hacterial  forms  of  purulent  arthritis  are  usually  gonorrheal, 
pneumo7iic,  or  typhoid  in  origin. 

Gonorrhea  in  either  the  acute  or  chronic  stages  may  give  rise  to 
metastatic  joint  inflammation  when  the  infected  urethra  is  subjected 
to  trauma  or  irritation,  or  when  the  cocci  have  penetrated  into  the 
deeper  layers  of  the  mucosa.  It  may,  in  some  instances,  be  properly 
ascribed  to  the  meddlesome  activities,  during  the  stage  of  acute  inflam- 
mation, of  so-called  specialists.  In  women,  pregnancy,  childbirth,  and 
the  postpartum  periods  seem  to  bear  a  provocative  relationship  to 
metastatic  invasion  (so-called  articular  rheumatism  of  pregnancy  and 
puerperium).  Gonorrheal  conjunctivitis  and  stomatitis  in  the  new- 
born is  at  times  complicated  by  gonorrheal  joint  affections. 

Gonorrheal  joint  inflammations  appear  in  all  joints ;  however,  they 
are  most  frequently  located  in  the  large  ones  (knee,  shoulder,  hip, 
elbow,  and  wrist),  and  may  invade  one  or  several  joints  at  a  time,  or 
successively  attack  one  joint  after  another  (mono-  or  polyarticular 
form) .  In  the  male  the  knee,  and  in  the  female  the  wrist,  joints  are 
most  frequently  involved  (Nasse*^").  Coincident  trauma  to  the  joint 
is  necessary  to  the  development  of  the  affliction. 

The  pathological  anatomy  of  the  process  takes  on  the  form  of  syno- 
vitis with  seropurulent,  serofibrinous,  or  serohemorrhagic  exudate  — 
rarely  with  a  purely  serous  or  purulent  effusion  {hydrops  articidaris 
serosus,  fihrinosus,  synovitis  piirulenta  catarrhalis)  ;  or  of  infiltration 
of  the  peri-  or  para-art icidar  soft  parts  with  serofibrinous  or  fibrino- 
purulent  exudate,  which  latter  only  moderately  fill  the  joint  cavity  but 
invade  the  capsule,  the  ligaments,  the  bursae,  and  other  tissues  con- 
tiguous to  the  joint  (Koenig,*^^  Nasse,*'^  Bennecke^').  The  process 
attended  with  periarticular  infiltrate,  the  so-called  phlegmonous  form 
(Koenig"^),  is  most  frequently  met  with. 

Mild  forms  of  the  disease,  not  attended  with  clinical  evidence  of 
pathological  changes,  expressed  by  pain  and  stiffness,  are  classified  by 
many  observers  as  arthralgia.  Koenig^^  regards  these  as  cases  of  mild 
fibrinous  inflammation. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      317 

# 

The  inflammatory  exudate  in  the  joint  and  in  the  soft  parts  contain 
gonococci  (Nasse^^).  Their  cultivation  on  suitable  media  is  not  diffi- 
cult when  the  specimen  is  obtained  from  fresh  cases  (first  week  of  the 
disease).  Mixed  infection  with  pyogenic  bacteria  causes  severe  puru- 
lent phlegmon  and  at  times  provokes  general  infection  (bacteremia). 
The  pus  excitants  may  be  derived  from  the  gonorrheal  focus  or  may 
be  introduced  into  the  joint  by  the  exploring  needle. 

The  onset  of  gonorrheal  joint  inflammation  is  so  frequently  acute 
that  its  sudden  development  is  of  diagnostic  significance.  In  not  a 
few  instances  the  onset  is  characterized  by  indefinite,  migratory,  pro- 
dromal muscle  and  joint  ''aches"  preliminary  to  a  subacute  articular 
involvement.  The  chronic  form  of  the  affliction  takes  on  the  form  of 
hydrops. 

Fever  is  not  a  marked  sj'mptom,  and  though  at  the  onset  it  may 
reach  a  considerable  elevation,  it  soon  recedes  when  the  affected  limb 
is  immobilized. 

The  course  of  the  disease  tends  toward  chronieity.  Hydrops  may 
recover  promptly  but  the  purulent  forms  (especially  phlegmon)  are 
obstinately  persistent,  yet  even  these  rarely  result  in  abscess  formation. 

Pain  and  swelling  continues  for  several  months,  during  which  the 
muscles  atropln'  and  the  joints  ankylose.  At  first,  fixation  is  due  to 
reflex  muscular  contraction ;  but  later,  contraction  of  the  peri-  and 
para-articular  tissues,  and  the  organization  of  fibrinous  deposits  on 
the  joint  surfaces  provoke  genuine  anJiylosis  (fibrosa  cartilaginosa) 
which  is  followed  by  absorption  of  articular  cartilages  and  ultimately 
leads  to  a  degree  of  osseous  deposit  that  entirely  obliterates  the  joint 
cavity.  This  ossification  makes  it  difficult,  if  not  impossible,  to  recog- 
nize the  location  of  the  joint  by  X-ray  or  upon  section. 

The  attendant  pain  and  toxemia  cause  serious  impairment  of  the 
patient's  general  health. 

The  sequelae  of  the  condition  consist  of  ankylosis,  malposition  from 
contracture,  and  suhluxation.  The  last  occurs  early  in  the  disease 
(second  week),  and  is  due  to  rapid  relaxation  of  the  ligaments 
(Bennecke®"). 

The  diagnosis  is  based  on  the  occurrence  of  effusion  without  the 
infiltration  of  surrounding  tissues  common  to  other  joint  inflamma- 
tions; on  the  sudden  onset ;  and  the  severe  pain  and  exquisite  tender- 
ness accompanying  the  early  stages  of  the  affliction.  In  the  phlegmo- 
nous form,  the  inflamed  part  is  doughy  and  fluctuates  only  in 
restricted  areas.    Clearly  defined  swelling  with  sharp  borders  is  absent. 


318  INFECTIONS  OF  WOUNDS 

The  skin  is  red,  hot,  and  edematous.  The  low  grade  of  fever  com- 
pared to  the  rather  extensive  local  involvement  should  exclude  pure 
pyogenic  infection.  However,  puncture  and  bacteriological  examina- 
tion clears  up  the  doubtful  cases.  Differentiation  from  acute  articular 
rheumatism  rests  on  the  persistence  with  which  gonorrhea  involves  one 
or  two  joints  only,  and  the  severity  of  the  pain  which  characterizes 
the  latter.  The  rarer,  subacute  and  chronic  forms  may  simulate  joint 
tuberculosis  or  syphilis.     Tumor  alhus  simulates  the  chronic  form. 

The  prognosis  as  regards  life  is  not  unfavorable.  A  fatal  outcome 
is  usually  due  to  endocardial  invasion.  The  function  of  infected 
joints  returns  after  h^^drops,  but  is  usually  permanently  impaired 
after  the  purulent  form  attended  with  infiltration  of  the  soft  parts. 

The  duration  of  the  disease  depends  upon  the  virulence  of  the 
infecting  excitant.  Recovery  in  less  than  a  month  is  not  to  be 
expected,  indeed,  a  period  of  illness  extending  over  several  months  is 
the  rule.  Persistence  of  the  primary  local  focus  involves  danger  of 
recurrence,  especially  in  joints  previously  invaded. 

The  treatment  with  Bier  s  obstruction  hyperemia  affords  benefit  in 
a  number  of  eases;  it  lessens  pain  and  permits  of  early  passive  and 
active  motion.  The  toxic  transudations  are  ultimately  absorbed.  The 
inflamed  joint  should  be  immobilized  until  the  acute  manifestations, 
including  fever,  have  subsided.  In  the  hip,  immobilization  may  be 
supplemented  advantageously  by  extension.  Faulty  position  of  the 
part  may  be  avoided  b}^  the  use  of  apparatus  designed  to  fit  the  indi- 
cations arising  in  a  given  case.  Excessive  effusion  may  be  treated  by 
aspiration  and  subsequent  elastic  pressure.  The  injection  of  5-8  c.cm. 
of  5  per  cent  carbolic  acid  solution  (Koenig^^)  and  5  c.cm.  of  tincture 
of  iodin  (Hildebrand*^^)  is  recommended.  Incision  is  indicated  only 
when  mixed  infection  with  pus  organisms  leads  to  abscess  formation. 

Ankylosis  is  subjected  to  active  and  passive  motioyi;  however,  when 
these  are  followed  by  inflammatory  reaction,  the  part  must  be  immo- 
bilized again  until  this  has  subsided.  Repeated  forcihle  stretching 
and  separation  of  the  ankylosed  parts  may  be  executed  under  narcosis. 
This  useful  measure  requires  considerable  persistence  and  fortitude 
on  the  part  of  the  patient ;  however,  the  results  thus  obtained  would 
seem  to  justify  its  employment. 

When  body  ankylosis  has  developed,  resection  of  the  joint  and  inter- 
position of  tissue  (Part  IV)  may  be  employed. 

The  treatment  of  gonorrheal  infections  with  active  immunizing 
injections  of  dead  gonococcus  cultures  (Bruck^^)  has  proved  valuable 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      319 

and  would  seem  to  be  worthy  of  application  in  cases  of  joint  inflam- 
mations (Scliultz""). 

In  the  course  of  fihrinous  pneumonitis,  mono-  or  poly-articular 
inflammations  due  to  pncumococci  occasionally  occur,  at  the  height  of 
the  process,  in  the  lung.  These  inflammations  are  acute  in  character 
and  take  on  the  form  of  serofibrinous  or  purulent  synovitis.  They 
are  to  be  regarded  as  the  outcome  of  bacteremia  which,  as  it  also  leads 
to  purulent  infection  of  the  endocardium  and  serous  cavities,  is  of 
unfavorable  prognostic  significance.  When  the  process  is  limited  to 
joints,  aspiration  affords  relief  for  the  serous,  and  incision  and 
drainage  for  the  purulent  form  of  the  disease.  Recovery  usually  is 
not  attended  with  the  sequelae  common  to  joint  infections. 

Pneumococcus  infection  of  joints  occurs,  at  times,  independent  of 
lung  invasion.  This  is  extremely  rare  in  the  adult ;  less  so  in  children, 
where  it  is  usually  a  complication  (by  extension)  of  osteomyelitis, 
originating,  no  doubt,  in  an  embolic  focus  derived  from  the  mucosa  of 
the  upper  air  passages. 

Typhaid  fever  is  also,  at  times,  attended  with  joint  infection  due  to 
its  specific  excitant.  The  joint  inflammation  usually  occurs  during 
convalescence  and  is  characterized  by  serous  and  serohemorrhagic 
effusion.  In  most  instances  the  course  of  the  affliction  is  benign  and 
is,  after  aspiration  and  immobilization,  followed  by  complete  recovery, 
unless  mixed  pyogenic  infection  with  staphylo-  or  streptococci  super- 
venes. In  the  latter  instance,  the  disease  is  characterized  by  happen- 
ings common  to  all  pyogenic  infections  of  joints. 

G.     PYOGENIC  INFECTIONS  OF  TENDON  SHEATHS  AND  BUESAE 

The  shcaflis  of  tendons  and  hursae  are  most  often  infected  in  con- 
nection with  wounds ;  by  means  of  foreign  bodies,  by  extension  from 
contiguous  purulent  processes  (suppurating  skin  wounds,  furuncle, 
subcutaneous  phlegmon,  erj^sipelas,  etc.),  and  —  less  frequently  —  by 
way  of  the  blood  current.  The  bacterial  excitants  are  usually  stapJiylo- 
and  streptococci,  the  latter  often  of  a  virulent  strain ;  at  times,  gono- 
cocci,  pneumococci,  and  bacilli  coli  communis  are  responsible  for  the 
infection. 

The  character  of  the  process  is  invariably  acute  and  is  attended 
with  fever  and  more  or  less  grave  constitutional  disturbances.  The 
inflammatory  exudate  is  at  first  serous  but  soon  becomes  purulent. 
The  process  progressively  involves  hursae  and  tendon  sheaths  in  accord 


320 


INFECTIONS  OF  WOUNDS 


ivith  the  anatomical  relationship  these  bear  to  each  other,  and  to  the 
port  of  entrance  of  the  infection. 

When  the  inflammation  is  restricted  to  a  bursa,  its  interior  becomes 
lined  with  granulations  (pyogenic  membrane).  If,  however,  the 
bursal  sac  sloughs  and  ruptures,  the  infection  is  liberated  into  the 
surrounding  tissues,  giving  rise  to  a  circumscribed  phlegmon  which 
ultimately  perforates  the  skin  and  is  often  followed  by  the  formation 
of  a  persistent  fistula;  or 
progressive  infiltrating 
phlegmonous  inflammation, 
invasion  of  tendon  sheaths, 
and  necrosis  of  tendons. 

Invasion  of  the  tendon 
sheath  is  soon  followed  by 
involvement  of  the  peri- 
tenonium  externum  and  in- 
ternum. The  investing  con- 
nective tissue  is  at  once  in- 
vaded by  leukocytes  and 
proliferated  cells.  In  from 
three  to  five  days  the  bundles 
of  tendon  fibers  unravel  and 
soon  become  necrotic.  When 
the  strands  of  dead  tendon 
remain  w  situ  they  act  as 
foreign  bodies  and,  like  bone 
sequestra,  cause  the  forma- 
tion of  fistulae  leading  from 
the  interior  of  the  imbed- 
ding  granulation  tissue.  ^^^-  137.- Prepatellar  Bursitis    (Johnson). 

Clinically,  suppurative  inflammation  of  a  bursa  {bursitis  acuta 
purulenta)  develops  rapidly,  is  attended  with  pain  (especially  on 
motion),  appears  as  a  circumscribed  swelling  corresponding  to  its 
location,  and  is  usually  surrounded  by  an  area  of  redness  and  edema 
which  merges  into  the  surrounding  normal  skin  (Fig.  137).  The 
outcome  of  the  process  is  either  rupture  on  the  surface  followed  by 
fistula,  or  an  extending  phlegmonous  inflammation  which  invades  the 
contiguous  soft  parts.  If  the  bursitis  follows  an  open  wound,  lymph- 
angitis or  erysipelas  often  accompanies  it. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      321 


Inflammation  of  tendon  sheaths. —  Tendovaginitis  acuta  purulenta 
—  phlegmon  of  the  tendon  sheaths,  panaritium  tendinosum,  begins 
with  rapidly  extending  pain,  tenderness,  and  loss  of  function  of  one 
or  more  tendons.  Usually  the  overlying  skin  is  slightly  reddened. 
Fluctuation  appears  when  pus  accumulates  to  a  considerable  extent  in 
restricted  areas  —  just  before  the  skin  ruptures. 

The  dangers  and  sequelae  of  purulent  bursitis  relate  to  the  extension 
of  the  process  into  a  contiguous  joint.     Those  of  tendovaginitis,  aside 

from  the  liability  of 
phlegmonous  extension, 
involve  the  risk  of  per- 
manent lessening  of 
function  —  the  outcome 
of  necrosis  of  the  tendon 
—  and  subsequent  con- 
tracture (Fig.  138). 
Systemic  infection  (bac- 
teriemia)  at  times  fol- 
lows extension  of  the 
process  into  the  sur- 
rounding tissues. 

Recognition  of  the  dis- 
ease is  based  on  the  loca- 
tian  of  the  inflammatory 
process.    Bursitis  is  pri- 
marily   localized    to    a 
bursal  area,  whilst  ten- 
dovaginitis   extends    in 
certain     definite     direc- 
tions.    Infection  of  the 
sheaths   of   the   2d,    3d, 
and  4th  fingers  extends  only  to  the  transverse  palmar  fold ;  that  of  the 
thumb  and  little  finger  invades  the  wrist  joint  and  forearm  since  com- 
munication between  these  parts  (superficially  and  deep)  is  direct. 

The  treatment  of  bursitis  acuta  purulenta,  like  that  of  all  suppura- 
tive processes,  consists  of  incision  and  drainage.  In  tendovaginitis 
two  factors  are  to  be  taken  into  account.  First,  the  earlier  the  sheath 
is  opened  and  unburdened  of  its  exudate  the  better  is  the  outlook  as 
regards  conservation  of  the  integrity  of  the  tendon,  and  the  less  are 
connective    tissue    adhesions    likely    to    interfere   with    its    motility. 


Fig.    138. —  Contracture    Following 
Tendinitis. 


Purulent 


322 


INFECTIONS  OF  WOUNDS 


Second,  the  liberating  incisions  should  be  made  with  the  view  of 
obviating  subsequent  cicatricial  contracture,  which  always  follows 
when  the  entire  length  of  a  tendon  sheath  is  opened  and  its  transverse 
filaments  divided.  It  is,  therefore,  lest  to  make  several  small  incisions, 
preferably  at  the  lateral  aspects  of  the  tendon,  alternating  first  one 
side  and  then  the  other.  Small  bridges  of  skin  should  be  left  intact, 
especially,  the  ligamentum  carpi  volare  should  be  spared.     In  many 


Fig.  139. —  A,  Lines  of  Incision  foe  Belief  of  Purulent  Tendovaginitis  of 
Flexor  Tendon  of  Index  Finger;  B,  Motility  of  Finger  After  Healing. 


cases  treated  in  this  way  recovery  is  attended  with  satisfactory  motion 
(Fig.  139). 

When  the  small  incisions  do  not  suffice  for  the  purpose  of  drainage, 
the  transverse  fibers  of  tendon  sheaths,  the  bridges  of  skin,  and  the 
joint  ligaments  must  be  divided.  This,  however,  seals  the  fate  of  the 
limb  as  regards  full  reestahlishment  of  function. 

In  the  presence  of  inflammations  of  moderate  degree,  immobilization 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      323 

and  elevation  of  the  part  may  result  in  recession  of  the  process,  mak- 
ing the  employment  of  the  more  drastic  measures  of  relief  unnecessary. 

In  all  cases,  early  employment  of  passive  and  active  motion,  prefer- 
ably in  hot  air  baths,  are  to  be  strongly  enjoined. 

The  treatment  of  cicatricial  contractures  is  unsatisfactory.  Mechan- 
ical stretching  of  the  scar  tissue,  especially  in  the  presence  of  joint 
ankylosis,  is  useless.  Forcible  stretching  is  followed  by  increased  con- 
traction. Excision  of  the  contracted  tissue  is  not  followed  by  improve- 
ment. The  only  means  of  relief  worthy  of  emplo^^nent  consists  of 
excision  of  scar  tissue  and  immediate  free  implantation  of  portions  of 
tendon. 

Amputation  is  indicated  Avhen  general  infection  develops  or  when 
the  faulty  position  of  fingers  interferes  wdth  the  patient's  work. 

Gonorrheal  Ijursitis  and  tendovaginitis  at  times  complicate  gonor- 
rheal arthritis.  They  are  attended  with  a  serous  exudate  when  the 
process  is  due  to  the  gonococcus  alone,  but  this  becomes  purulent  when 
pyogenic  excitants  are  added.  The  affliction  is  also  followed  by  con- 
tractures and  deformities  due  to  connective  tissue  hyperplasia. 

Of  the  bursae,  that  of  the  tendo  Achillis,  and  of  the  tendon  sheaths, 
those  of  the  flexors  of  the  fijigers  and  the  extensors  behind  the  internal 
malleolus  are  most  commonly  invaded  by  gonococci  (Nasse^^). 

Immobilization  of  the  inflamed  part,  aspiration  in  moderate  cases, 
and  incision  and  drainage  in  severe  cases  of  purulent  infections,  are 
usually  followed  by  prompt  recover}^ 

Chronic  thickening  from  connective  tissue  genesis  occasionally 
occurs  (Nasse^^). 

H.     PYOGENIC  INFECTIONS  OF  MUSCLES  AND  SUBFASCIAL  AND 
INTERMUSCULAR  PHLEGMON 

Myositis. —  Myositis  acuta  purulenta  develops  in  various  ways, 
involving  both  the  interstitial  tissue  and  the  muscle  fiber.  Infections 
of  the  interstitial  tissues  take  on  the  form  of  serous,  serofibrinous  and 
purulent  inflammations,  while  those  of  the  muscle  fiber  appear  as 
parenchymatous  degenerative  processes. 

Ectogenous  infections  are  the  result  of  pus  excitants  of  various 
kinds,  and  of  putrefactive  bacteria  which  gain  access  through  lacerated 
and  contused  wounds  of  the  musculature  (compound  fractures,  gun- 
shot wounds,  tearing  of  the  soft  parts  by  machinery,  etc.) .  Compound 
fractures  are  often  not  infected  when  the  injury  to  the  soft  parts  is 


324  INFECTIONS  OF  WOUNDS 

moderate  in  degree,  unless  efforts  at  treatment,  such  as  undue  manipu- 
lations, probing,  and  irrigation  introduce  infective  substances  or 
spread  them  into  the  deeper  parts. 

Extension  of  the  infection  is  attended  by  the  development  of  er^'sip- 
elas  phlegmonosum,  lymphangitis,  phlebitis,  osteomyelitis  (purulenta), 
etc.,  which  usually  primarily  invade  the  loose  connective  tissue  inter- 
muscular septae,  and,  after  destroying  the  perimysium,  extend  to  the 
muscle  fiber  and  cause  its  destruction. 

Hematogenous  purulent  myositis  occurs  as  part  of  a  general  infec- 
tion (bacteriemia)  and  appears  in  one  or  more  muscles  in  the  form  of 
circumscribed  abscesses;  the  result,  usually,  of  staphylo-  or  strepto- 
coccus invasion.  In  some  instances  the  causative  excitants  are 
pneiimo-  or  gonococci,  or  coli  and  typhoid  'bacilli  (in  the  course  of 
typhoid  fever)  or  influenza  hacilli.  Subcutaneous  contusions,  lacera- 
tions, ruptures,  etc.,  with  hematomata,  because  of  the  lessened  resist- 
ance of  the  tissues  (locus  minoris  resistantiae),  present  conditions 
favorable  to  the  activities  of  pyogenic  bacteria  derived  from  focal 
infections  elsewhere  (panaritic,  angina,  etc.),  and  often  break  down, 
forming  extensive  areas  of  suppuration  and  necrosis. 

The  onset  of  myositis  is  characterized  by  massive  swelling  of  the 
invaded  muscle,  severe  localized  pain,  complete  abolition  of  function, 
and  fever.  Palpation  reveals  a  hard,  thick  infiltration  which,  because 
of  the  edema  of  the  surrounding  soft  parts  and  overlying  skin,  is  not 
clearly  defined.  When  suppurative  dissolution  occurs,  fluctuation 
becomes  manifest,  the  skin  reddens,  ultimately  ruptures,  and  permits 
of  the  escape  of  the  exudate. 

Extension  of  the  process  leads  to  invasion  of  the  interstitial  tissues, 
suppurative  necrosis  of  the  entire  muscle,  and  the  involvement  of  con- 
tiguous parts.  This  form  of  myositis  is  frequently  followed  by  per- 
manent loss  of  function,  the  result  of  scar  tissue  contraction,  and,  at 
times,  gives  rise  to  fatal  general  infection. 

Localization  of  suppurative  myositis  occurs  when  reparative  granu- 
lation tissue  genesis  succeeds  in  encapsulating  the  inflammatory  focus. 
The  investing  pyogenic  membrane  of  these  abscesses  is  very  delicate. 
Early  drainage  is  followed  by  prompt  healing  and  little  ultimate  loss 
of  function. 

Secondary  myositis,  due  to  an  extension  of  a  contiguous  purulent 
bone  or  gland  lesion,  usually  is  manifested  by  the  formation  of  a  serous 
exudate  and  recedes  spontaneously  when  the  cause  is  removed.  It 
does  not,  however,  heal  without  the  formation  of  scar  tissue  (myositis 


.    PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      325 

fibrosa)  which,  more  or  less,  impairs  the  function  of  the  affected 
muscle. 

Recognition  of  myositis  is  based  on  the  palpation  of  a  hard,  tender 
mass  corresponding  to  the  location  of  a  muscle  and  extending  within 
its  confines.  When  much  edema  of  surrounding  soft  parts  is  present, 
it  may  be  confused  with  deep  lymphangitis  or  osteomyelitis. 

The  treaiment  consists  of  early,  free  incision  executed  in  the  direc- 
tion of  the  muscle  fiber,  care  being  taken  to  separate  these  and  avoid, 
as  far  as  possible,  their  transverse  division.  Beyond  this,  the  treat- 
ment is  based  en  the  measures  already  fully  described  in  connection 
with  pyogenic  infections  generally  (p.  240). 

Functional  impairment,  the  result  of  scar  tissue  contraction  (fibrous 
myositis),  may  be  lessened  by  muscle  transplantation. 

Subfascial  and  Intermuscular  Phlegmons. —  Subfascial  and  intermus- 
cular phlegmons  (which  merge  into  each  other)  result  from  the  exten- 
sion of  subcutaneous  phlegmon;  from  rupture  of  purulent  inflamma- 
tions of  tendons,  muscles,  joints,  bones,  and  the  tissues  surrounding 
the  esophagus  and  trachea ;  from  infection  of  deeply  located  trauma 
(stab  wounds,  etc.)  ;   or  they  are  metastatic  in  origin. 

The  infection  is  characterized  by  its  progression  between  the 
muscles,  especialh'  along  the  course  of  the  large  vessels  (neck,  axilla, 
popliteal  space,  etc.),  where  the  connective  tissue  is  abundant.  The 
process  appears  as  a  boardlike  infiltration  of  the  soft  parts  attended 
with  slight  redness  and  edema  of  the  skin,  fever,  pain,  and  loss,  or 
lessening  of  function.  Under  favorable  conditions  the  infiltrate  soft- 
ens and  the  exudate  is  spontaneously  discharged  upon  the  skin ;  often, 
however,  menacing  complications  result  from  the  extension  of  the 
inflammation  which,  unfortunately,  is  at  times  favored  by  the  use  of 
poultices  (v.  Bergmann'^).  Phlegmon  of  the  neck  frequently  invades 
the  mediastinum  or  provokes  fatal  edema  glottidis. 

Early  free  incision  alone  is  helpful.  The  enmantled  blood  vessels 
and  the  invaded  intermuscular  spaces  must  be  widely  exposed.  "When 
tube  drainage  is  employed,  care  must  be  taken  to  avoid  pressure 
erosion  of  blood  vessels  (see  arteritis). 

Wooden  Phlegmon. —  Wooden  phlegmon,  first  described  by  Reclus, 
is  a  term  applied  to  a  peculiar  diffuse  inflammation  involving  the  sub- 
cutaneous and  intermuscular  tissues  (especially  the  neck),  is  char- 
acterized b}'  a  hoard-liJie,  almost  pauiJess  infiltration  of  the  soft  parts, 
and  shows  little  tendency  to  suppurate. 

The  causative  excitants  have  been  found  to  be  strepto-,  stapJujlo-, 


326  INFECTIONS  OF  WOUNDS 

pneumococci,  and  diphtheria  hacilli,  though  the  presence  of  bacteria  in 
the  exudate  has  never  been  demonstrated  (Kusnetzoff^-). 

The  port  of  entrance  of  the  infection  is  located  in  the  floor  of  the 
mouth  or  in  the  pharynx.  It  is  probable  that  the  moderate  virulence 
of  the  bacterial  aggressors  accounts  for  the  absence  of  necrosis  and 
suppuration. 

Early  incision  of  the  neck,  at  times  imperatively  necessary  for  the 
relief  of  pressure  and  edema  glottidis,  reveals  the  tissues  heavily  infil- 
trated with  a  turbid,  perhaps  slightly  purulent,  exudate,  especially  in 
the  submaxillary  region  where  the  glandular  structures  are  found 
deeply  embedded. 

The  process  is  easily  confused  with  actinomycosis  which  is  under- 
standable, since  the  latter  is  also  characterized  by  boardlike  infiltration 
of  the  tissues. 

The  treatment  consists  of  free  incision  and  exposure  of  the  infil- 
trated intermuscular  spaces  before  pus  is  present,  with  the  view  of 
causing  expulsion  of  the  exudate.  It  is  true  that  the  application  of 
heat  in  the  form  of  poultices  may  be  followed  ultimately  by  softening 
of  the  exudate  and  its  discharge ;  however,  the  danger  of  sudden 
extension  of  the  process  with  its  dire  possibilities  makes  early  incision 
the  treatment  of  choice. 

I.     PYOGENIC  INFECTIONS  OF  SEROUS  CAVITIES  AND  THE 
VARIOUS  ORGANS 

Pyogenic  infections  of  serous  cavities  are  ectogeiious  or  endogenous 
in  origin.  The  ectogenous  form  is  due  to  the  introduction  of  provoca- 
tive excitants  by  means  of  trauma  —  stab  or  gunshot  wounds.  The 
endogenous  form  is  consequent  to  perforation  of  organs  contiguous  to 
serous  spaces,  such  as  happens  when  peritonitis  follows  subcutaneous 
rupture  or  strangulation  of  the  intestine,  rupture  of  a  gastric  ulcer, 
etc.;  when  pleuritis  develops  from  a  ruptured  bronchus,  or  a  com- 
pound fracture  of  a  rib,  etc. ;  and  when  meningitis  complicates  a 
fracture  of  the  base  of  the  skull  involving  the  middle  ear  or  the 
cribriform  plate  of  the  ethmoid  bone. 

The  lymphogenous  or  extension  form  of  the  infection  is  not  uncom- 
mon. Its  occurrence  may  be  illustrated  in  connection  with  the  causa- 
tive relationship  between  pleuritis  and  lung  abscess;  pneumonitis  and 
osteomyelitis  of  a  rib ;  meningitis  and  suppurative  osteomyelitis  of 
the  skull  with  thrombophlebitis  and  bacteremia;    empyema  and  sup- 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES       327 

purative  peritonitis  by  transmigration  through  the  diaghragm; 
pyonephrosis  and  cystitis;  etc. 

Hematogenous  infections  invade  organs  and  serous  cavities  simulta- 
neously with  their  appearance  in  other  parts  and  tissues  of  the  body 
as  a  part  of  a  general  systemic  process  attended  with  metastases.  In 
this  way  multiple  pyogenic  foci  appear  in  the  lungs  as  the  result  of  the 
lodgment  there  of  infected  emboli;  the  liver  is  similarly  invaded  by 
way  of  the  portal  circulation. 

Pyogenic  inflammation  of  serous  cavities  may  be  divided  into  three 
general  forms:  The  encapsulated,  the  acute  progressive,  and  the 
general,  all  of  which  are  attended  with  the  formation  of  exudates 
similar  to  those  found  elsewhere  in  the  body.  In  the  encapsulated 
form  the  edges  are  found  covered  with  a  layer  of  fibrinous  deposit  and 
a  zone  of  granulation  tissue  which  cause  the  apposed  surfaces  of  the 
serous  membrane  to  adhere  to  each  other.  In  the  acute  progressive 
form,  segregation  of  the  inflamed  area  does  not  take  place,  or,  a  tem- 
porary isolation  is  soon  followed  by  the  breaking  down  of  the  encap- 
sulating deposit  and  the  process  gradually  extends  until  the  entire 
serous  cavity  is  involved,  when  the  process  may  be  said  to  have  taken 
on  the  general  form. 

This  is  well  illustrated  in  cases  of  purulent  peritonitis,  in  which  the 
acute  progressive  form  is  frequently  halted  by  the  operative  removal 
of  the  cause,  even  though  a  considerable  area  of  the  peritoneum  is 
already  involved,  while  the  general  form  always  results  fatally. 

Inflammations  of  serous  membranes  have  been  made  the  object  of 
careful  investigation,  especially  in  connection  with  suppurative  pro- 
cesses involving  the  peritoneum.  The  defensive  activities  of  serous 
membranes  do  not  differ  from  those  of  other  tissues.  The  extensive 
surface  of  the  peritoneum  readily  absorbs  infectious  bacterial  excitants 
and  their  toxins,  and  is  of  efficient  help  in  segregating  inflammatory 
processes  invading  it  from  contiguous  organs  (Danielson'^^).  Per 
contra,  when  virulent  infectious  processes  are  already  established 
within  the  peritoneum,  especially  in  connection  with  gastric  and  intes- 
tinal perforations,  this  very  absorptive  capacity  soon  leads  to  general 
infection  and  death. 

The  more  active  the  local  inflammation,  the  sooner  encapsulation 
occurs  and,  of  course,  the  more  is  absorption  hindered.  The  local 
lesion  begins  with  the  destruction  of  the  endothelial  cells,  which  are 
exceedingly  susceptible  to  mechanical  and  chemical  influences,  and  are 
especially  sensitive  to  the   action   of  bacterial   poisons.     Fibrinous 


328  INFECTIONS  OF  WOUNDS 

exudate  is  immediately  deposited  upon  areas  denuded  of  endothe- 
lium, a  process  which  is  eorj.cerned  in  forming  the  protective  aggluti- 
nation of  serous  surfaces,  so  necessary  to  the  success  of  abdominal 
surgery.  Localized  areas  of  peritoneal  inflammation  are  surrounded 
by  a  wide  zone  of  hyperemia  which  furnishes  the  material  concerned 
in  encapsulation.  The  attendant  serous  exudate  dilutes  the  toxins  and 
acts  as  a  bactericide.  Severe  forms  of  pyogenic  infection  are  charac- 
terized by  the  formation  of  fibropurulent,  or  purulent,  exudate,  and 
putrefactive  processes  with  putrescent  exudate  deficient  in  fibrin. 

Pyogenic  infection  of  organs  appear  in  two  forms :  Circumscribed 
foci,  usually  multiple  in  a  single  organ ;  and  an  acute  progressive  form 
in  which  the  entire  organ  is  infiltrated. 

A  discussion  of  the  clinical  course,  the  diagnosis,  and  the  treat- 
ment of  pyogenic  infection  of  organs  is  taken  up  in  the  discussion  of 
Regional  Surgery. 

In  a  general  way,  the  treatment  consists  of  free  liberal  drainage 
of  infected  serous  cavities,  and  purulent  foci  located  in  organs. 
Simple  puncture  and  aspiration  rarely  suffices  the  purpose,  though 
early  measures  of  this  sort  would  seem  to  have  been  followed  by  arrest 
of  the  inflammatory  processes  in  pleuritis,  meningitis  (lumber  punc- 
ture), pericarditis,  etc. 

At  times  prolonged  inflammation  of  certain  organs  is  an  indication 
for  their  removal  (nephrectomy,  castration,  oophorectomy  splenec- 
tomy, etc.). 

BIBLIOGRAPHY 

1.  ScHiMMELBUSCH.     Arch.  f.  Ohrenhellk.,  Bd.  27. 

2.  KocHER.     Berlin  and  Leipzig,  1895. 

3.  V.  Bergmann.     Berlin  klin.  Woch.,  1901. 

4.  Fehleisen.     Verh.   d.   Wiirzb.  phys.   med.   Gesellsch.   Sitzungsbericht, 

Aug.,  1881. 

5.  Petruschky.     Zeitschr.  f.  Hyg.  Bd.  17,  1894. 

6.  Respinger.     Beitr.  z.  klin.  Chir.,  Bd.  26,  1900. 

7.  Jordan.    Miinch.  med.  Woch.,  1901. 

8.  JocHMANN.     Mitth.  a.  d.  Grenzgeb.  Bd.  16,  1906. 

9.  Rheiner.     Quoted  by  Pfuhl  No.  11. 

10.  Kocher.     Chir.  Operationslehre,  Jena,  1907. 

11.  Pfuhl.     Zeitschr.  f.  Hyg.  u.  Infektkranke,  Bd.  12,  1892. 

12.  V.  Noorden.    Miinch.  med.  Woch.,  1887. 

13.  Friederich.     Miinch.  med.  Woch.,  1897. 

14.  BuscH.     Berlin,  klin.  Woch.,  1866. 

15.  V.  Bruns.     Beitr.  z.  klin.  Chir.  Bd.  iii,  1888. 

16.  RosENBACH.     Chir.  Kong.  Verhand.  ii,  1887. 

17.  Tavel.     Deutseh.  Zeitschr.  f.  Chir.  Bd.  61,  1901. 

18.  Lexer.     Allgemeine  Chir.  Bd.  i,  Stuttgart,  1914. 

19.  Ohlemann.     Gottingen,  1904. 


PYOGENIC  INFECTIONS  OF  VARIOUS  TISSUES      329 

20.  V.  Mikulicz  and  Kummel.    Jena,  1909. 

21.  Feder.     Jena,  1900. 

22.  E.  FisCHEK.     Deutsch.  Cliir.,  1901,  mit  lit. 

23.  NOTZEL.     Beitr.  z.  klin.  Chir.  Bd.  51,  1906,  also  Bd.  65,  1909. 

24.  NosKE.     Zenthbl.  f.  Chir.,  1910. 

25.  Thorn.     Deutsch.  med.  Woch.,  1897,  Therap.  Beilage. 

26.  Talke.     Beitr.  z.  klin.  Cliir.  Bd.  36,  1902. 

27.  W.  MiJLLER.     Arch.  f.  kUn.  Chir.  Bd.  66,  1902. 

28.  Trendelenburg.     Muench.  med.  Woch.,  1902. 

29.  Lexer.     Arch.  f.  klin.  Chir.  Bd.  48,  1894. 

30.  Lexer.     Arch.  klin.  Chir.  Bd.  53,  1896. 

31.  AcKERMANN.     Quoted  by  Lexer  No.  29. 

32.  Lexer.     Arch.  klin.  Chir.  Bd.  52,  1896. 

33.  Ullmann.     Wien  med.  Press,  1900. 

34.  Jordan.     Beitr.  z.  klin.  Chir.  Bd.  10,  1893. 

35.  Weichselbaum.     Verh.  d.  Gesell.  deutsch  Naturforsher,  1894,  Wien. 

36.  Lexer.     Arch.  f.  klin.  Chir.  Bd.  71,  1903,  and  Bd.  73,  1904. 

37.  DuMONT.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  122,  1913. 

38.  Gangolphe.     Paris,  1894. 

39.  Garre.     Beitr.  z.  klin.  Chir.  Bd.  10, 1893. 

40.  Reiss.     Arb.  aus  v.  Bergmanu's  Klinik,  Berlin,  Bd.  15,  1901. 

41.  MiJLLER.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  55,  1900. 

42.  Lexer.     Arch,  f .  klin.  Chir.  Bd.  57,  1898. 

43.  Ollier.     Paris,  1867. 

44.  Schlange.     Arch.  f.  klin.  Chir.  Bd.  36,  1887. 

45.  Vollert.     Samml.  klin.  Vortr.  352,  1890. 

46.  Lexer.     Samml.  klin.  Vortr.  N.  F.  173,  1897. 

47.  MoSETiG-MoORHOP.     Deutsch.  Zeitschr.  f.  Chir.  Bd,  71,  1904. 

48.  V.  Mangold.     Chir.  Kong.  Verb.,  1904,  ii. 

49.  Makkas.     Beitr.  z.  klin.  Chir.  Bd.  77,  1912. 

50.  Frangenheim.     Arch.  f.  klin.  Chir.  Bd.  83,  1907. 

51.  Regnault.     Bull,  et  mem.  de  la  soc.  Anat.  de  Paris  No.  5,  1900. 

52.  Klemm.     Samml.  klin.  Vortr.  No.  234,  1899. 

53.  Holmberg.     Zentrbl.  f.  Chir.,  1909. 

54.  Heymann.     Deutsch.  med.  Woch.,  1909. 

55.  Finger.     Arch.  f.  Denn.  u.  Sypb.  Bd.  28,  1894. 

56.  ScHLAGENHAUFER.     Zentrl)l.  f.  Bakt.  Bd.  31,  1902. 

57.  Wrede.     Chir.  Kong.  Verhand.,  1900,  ii. 

58.  Wyssokowicz.     Mittheil  a.  d.  Grenzgeb.  Bd.  13,  1904. 

59.  Haekel.     Arch.  f.  klin.  Chir.  Bd.  39,  1889. 

60.  Wegner.     Virchow's  Arch.  Bd.  55,  1872. 

61.  V.  Steubenrauch.     Samml.  klin.  Vortr.  N.  F.,  303. 

62.  Riedel.     Chir.  Kong.  Verb.,  1896,  ii. 

63.  Notzel.     Arch,  f .  klin.  Chir.  Bd.  81,  1906. 

64.  HOFFA.     Chir.  Kong.  Verb.,  1892,  i. 

65.  Nasse.     Samml.  klin.  Vortr.  N.  F.  181,  1897. 
{J6.  Koenig.     Deutsch.  med.  Woch.,  1896. 

67.  Bennecke.     Berlin,  1899. 

68.  Hildebrand.     Berlin,  klin.  Woch.,  1911,  No.  31. 

69.  Bruck.    Miinch.  med.  Woch.,  1913,  No.  22. 

70.  SCHULTZ.    Deutsch.  med.  Woch.,  1911,  No.  50. 

71.  V.  Bergmann.     Ai-b.  aus  der  v.  BergTuann  Klinik,  Bd.  15,  1901. 

72.  Kusnetzoff.     Arch.  f.  klin.  Chir.,  Bd.  58,  1899. 

73.  Danielson.     Beitr.  z.  klin.  Chir.,  Bd.  54,  1907. 


CHAPTER  XI 

GENERAL  PYOGENIC  IXFECTIONS 

Any  local  pyogenic  infection  may  be  the  primary  focus  from  which 
bacteria  and  bacterial  toxins  gain  access  to  the  lymph  and  blood 
vessels  and  enter  the  general  circulation.  This  phenomenon  provokes 
a  combat,  the  character  of  which  depends  upon  the  virulence  of  the 
aggrassors,  and  the  toxicity"  of  their  products  manifested  b}^  fever 
and  its  allied  symptoms.  These  manifestations  may  be  said  to  be 
an  expression  on  the  part  of  the  body  of  its  capacity  to  overcome  the 
pernicious  activities  of  the  invaders. 

To  this  extent,  the  systemic  dissemination  of  the  products  of  local 
infection  may  be  said  to  serve  a  useful  purpose,  and  no  doubt  the 
part  the  system  as  a  whole  plays  under  these  conditions  is  exercised  in 
many  instances  in  which  there  are  no  clinical  evidences  of  so-called 
general  infection. 

When,  however,  the  invading  bacteria  succeed  in  overcoming  the 
forces  marshaled  against  them  and  gain  access  to  the  circulation  in 
large  quantities  they  are  deposited  by  it  in  certain  regions,  where  they 
provoke  new  areas  of  purulent  inflammation  (metastases)  or  rapidly 
multiply  in  the  blood  stream. 

When  the  balance  of  power  is  attained  by  the  invaders,  that  is, 
when  the  activities  of  the  invading  bacteria  are  greater  than  the 
defensive  capacity  of  the  body,  general  pyoge^iic  infection  is  estab- 
lished. General  pyogenic  infection  may  be  divided  into  two  basic 
forms  which,  however,  merge  into  each  other.  As  the  chief  differen- 
tiating characteristic  lies  in  the  occurrence  of  purulent  metastases  in 
the  one,  and  the  multiplication  of  bacteria  in  the  blood  in  the  other, 
the  former  may  be  designated  as : 

Pyogenic  metastatic  general  infection  attended  with  transient 
bacteremia  {metastatic  infection),  and  the  latter  as: 

Pyogenic  non-metastatic  general  infection  attended  with  persis- 
tent (toxic  and  bacterial)  blood  invasion  {hlood  infection). 

330 


GENERAL  PYOGENIC  INFECTIONS  331 

In  the  metastatic  form  the  circulation  is  simply  the  avenue  of  ap- 
proach by  means  of  which  the  bacteria  are  enabled  to  distribute  them- 
selves in  the  form  of  foci.    This  occurs  in  two  ways : 

First,  the  bacteria  penetrate  the  walls  of  vessels  located  within  the 
primary  focus,  where  they  form  small  groups  {bacterial  emboli)  or  are 
embedded  in  minute  fibrinous  particles  {infectious  eynholi)  derived 
from  the  walls  of  infected  blood  vessels  similarly  located,  and  are 
carried  by  the  blood  current  to  more  or  less  remote  parts,  organs,  and 
tissues,  where  they  provoke  metastatic  inflammation,  often  in  the  form 
of  an  infarct. 

Second,  bacteria,  or  their  toxins,  are  intermittently  present  in  the 
blood  and  in  the  organs,  appearing  daily,  or  every  few  days  at  regu- 
lar or  irregular  intervals,  depending  upon  the  frequency  with  which 
the  bactericidal  power  of  the  body  is  lessened  and  reasserted.  The 
repeated  production  of  new  bactericides  takes  care  of  the  bacteria 
in  the  blood,  but,  in  the  meantime,  large  numbers  of  viable  bacteria  are 
constantly  deposited  in  certain  portions  of  the  body  (bone  marrow  in 
the  young,  joints  and  organs)  where  they  provoke  the  development  of 
new  areas  of  inflammation. 

Every  hematogenous  suppurative  process  must,  of  necessity,  be  an 
expression  of  general  pyogenic  infection  irrespective  of  a  discoverable 
port  of  entrance;  however,  from  a  clinical  standpoint,  single  metas- 
tatic inflammations  of  this  sort  are  not  regarded  as  a  part  of  a  general 
infection  unless  attended  with  the  blood  picture  and  systemic  sjTnp- 
toms  indicated  in  this  connection. 

The  non-met asteitic  form  is  attended  ivith  the  persistent  presence  of 
bacteria  and  bacterial  toxins  in  the  blood.  Theoretically,  bacterial 
general  infection  (bacteremia)  — when  bacteria  predominate,  and 
toxic  infection  (toxemia)  — when  toxins  predominate  in  the  blood,  are 
two  distinct  conditions,  though,  clinically,  they  cannot  be  separated 
from  each  other. 

In  bactcried  general  infection,  the  excitants  derived  from  the  pri- 
mary focus  multiply  in  the  blood  with  such  rapidity  that  the  organ- 
ism is  incapable  of  producing  bactericides  in  sufficient  quantity  to 
destroy  them  (septicemia  of  the  bacteriologist).  Indeed,  the  activi- 
ties of  the  bacteria  are  of  a  nature  which  precludes  the  development  of 
local  suppuration. 

In  toxic  general  infections  (tetanus),  the  toxic  products  of  the 
bacteria  developed  in  the  focus  are  taken  up  by  the  blood  in  large 
quantities.      This   form   can  be   diagnosticated   with   certainty   only 


332  INFECTIONS  OF  WOUNDS 

when  negative  blood  findings  are  associated  with  definite  symptoms  of 
a  disease  known  to  be  due  to  toxic  infection.  It  occurs  in  cases  in 
which  putrefactive  organisms  coexist  with  pyogenic  excitants. 

As  either  of  the  basic  forms  of  pyogenic  infection  may  merge  into 
the  other,  it  is  understandable  that,  in  the  transition,  many  variations 
make  their  appearance.    In  this  connection,  Lexer'^  says: 

"The  employment  of  a  special  terminology  for  these  transitional 
forms  of  general  infection  presents  a  difficult  problem,  and  is,  per- 
haps, an  unnecessary  effort.  The  term,  septicopyemia  is  largely 
used  for  the  purpose  of  characterizing  the  simultaneous  presence  of 
bacteria  and  the  products  of  putrefaction  in  the  blood.  The  terms 
sepsis,  septicemia,  septemia  are  in  no  sense  indicative  of  the  conditions 
presented  and  quite  properly  may  be  excluded  from  surgical  termin- 
ology. They  would,  however,  be  properly  used  in  connection  with  the 
symptoms  attendant  upon  the  entrance  into  the  blood  of  the  products 
of  putrefaction,  especially  in  eases  of  gas  and  gangrene  producing  in- 
fections, were  it  not  for  the  fact  that  each  author  feels  justified  in 
employing  them  as  descriptive  of  other  conditions.  For  instance, 
Gusvsenbauer^  and  Brunner^  employ  the  term  ''sepsis;"  Lenhartz* 
also  employs  the  term  "  sepsis,"  but  adds  general  infection  to  it, 
i.  e.,  septic  general  infection;  v.  Wassermann^  included  under  the 
head  of  septicemia,  bacterial  blood  infection  and  bacteremia,  especially 
when  due  to  streptococci,  but  not  anthrax  or  pest ;  septicemia  is  also 
used  by  v.  Kahlden,^  who  adds  toxicemia  irrespective  of  whether  the 
process  is  putrefactive  or  pyogenic  in  character;  "W.  Guttman  (Med. 
Terminology)  groups  septicemia,  pyemia,  and  lymphangitis  under 
the  head  of  sepsis.  Bondy'^  covers  all  pyogenic  and  putrefactive 
general  infections  with  the  term  'septic  general  infection.' 

In  order  to  escape  this  confusion  and  to  make  easier  an  understand- 
ing of  the  conditions,  it  is  best  to  designate  putrefactive  processes  and 
their  attendant  systemic  pathogenesis  under  the  term  "putrid  infection 
and  general  infection. ' ' 

The  use  of  the  term  pyemia  or  pyoJiemia,  introduced  by  Piorry 
C1840),  to  describe  the  entrance  of  pus  into  the  blood,  should  also 
be  discontinued,  as  it  is  applied  to  general  pyogenic  infection  whether 
bacteriemia  alone,  or  bacteriemia  with  metastases,  or  metastases  with- 
out bacteriemia  exists. 


GENERAL  PYOGENIC  INFECTIONS  333 

A.    PYOGENIC  GENERAL  INFECTION  WITH  METASTASES 
{Metastatic  Infection) 

All  pyogenic  excitants  resident  in  a  local  area  of  infection  are 
capable  of  developing  metastatic  foci.  Staphylococci  are  most  often 
concerned  in  processes  of  this  sort ;  streptococci  are  next  in  frequency 
and  seem  to  exhibit  a  tendency  to  invade  with  pyogenesis,  the  joints 
and  serous  cavities,  and  to  provoke  phlegmon  and  erysipelas.  Pncu- 
mococci,  gonococci,  coli,  and  typhoid  bacilli  are  also,  though  less  fre- 
quently, concerned  in  metastatic  invasions.  Mixed  infections  of 
staphylo-  and  streptococcic  origin  are  not  uncommon. 

Bacteria  gain  access  to  the  circulation  by  absorption  or  enter  it 
through  the  walls  of  damaged  blood  vessels,  or  are  contained  in  fibrin 
particles  avulsed  from  a  thrombus  (infected  emboli). 

The  important  sources  of  metastatic  inflammations  are: 

First,  severely  infected  wounds,  especially  when  the  lesion  presents 
conditions  favorable  to  infection,  such  as  obtains  in  connection  with 
lacerations  and  contusions  with  infiltration  of  blood  and  necrosis;  com- 
pound complicated  fractures;  injuries  produced  by  machinery,  gren- 
ades, shrapnel  and  shell  splinters;  the  interior  of  the  post  partum 
uterus,  etc.,  all  of  which  present  a  favorable  field  for  the  activities  of 
pyogenic  and  putrefactive  bacteria,  both  of  M"hich  are  likely  to  take  on 
exceedingly  virulent  characteristics. 

Second,  local  inflammatory  processes  of  all  kinds,  the  primary, 
such  as  furuncle,  phlegmon,  erysipelas,  infections  of  the  mucosa  (es- 
pecially angina,  empyema  of  the  accessory  sinuses  of  the  nose,  otitis 
media,  etc.),  and  the  secondary,  such  as  lymphangitis,  thrombophle- 
bitis, or  already  established  hematogenous  processes,  such  as  endo- 
carditis, arthritis  and  osteomyelitis  purulenta. 

Third,  ulcerations  of  all  kinds  (tuberculosis,  typhoid,  lues,  carci- 
noma) may  become  ports  of  pyogenic  infection. 

The  operation  wound  of  to-day  is  rarely  responsible  for  tfhe 
entrance  of  infection. 

Although  it  is  not  possible  in  all  cases  of  general  infection  to  demon- 
strate the  presence  of  a  local  inflammatory  focus,  it  is,  nevertheless, 
proper  to  assume  that  one  is  present  but  has  escaped  detection.  These 
so-called  cryptogenic  cases  may  be  explained  on  the  ground  that  a 
minor  infection  of  the  skin  (furuncle)  or  mucosa  may  heal  on  the 
surface,  but  that  an  underlying  moderate  thrombophlebitis  oj*  \yra- 


334  INFECTIONS  OF  WOUNDS 

phangitis  may  still  be  responsible  for  the  introduction  of  infectious 
bacteria  into  the  general  circulation. 

The  generalization  of  infection  is  provoked  by  those  means  that 
increase  the  absorption  of  bacteria  and  bacterial  toxins  from  a  local 
focus  of  infection  and  favor  their  entrance  into  the  veins  and  lymph 
vessels  of  the  body.  These  are  trauma  and  mechanical  irritation  of 
the  infected  tissues,  which,  unfortunately,  frequently  occur  in  the 
treatment  of  wounds. 

The  localization  of  hematogenous  processes  is  favored  by  trauma 
and  by  those  processes  that  lessen  the  resistence  of  the  tissues  of  a 
certain  zone.  Lacerated  tissues,  or  those  in  which  the  circulation  is 
interfered  with,  do  not  offer  the  same  resistance  to  bacterial  invasion 
as  is  evidenced  by  healthy  ones.  Thus,  a  simple  fracture  or  a  subcu- 
taneous hematoma  is  very  likely  to  be  the  area  of  localization  of  pyo- 
genic bacteria  derived  from  an  infected  tonsil,  an  angina,  etc.,  and 
an  acute  infectious  inflammatory  process  be  developed. 

In  addition  to  this,  it  would  seem  that  certain  tissues  and  organs 
of  the  body  possess  special  characteristics  (not  clearly  defined)  which 
render  them  particularly  liable  to  the  localization  of  hematogenous 
infection.  Pathogenic  doses  of  pyogenic  bacteria  (especially  staphylo- 
cocci) injected  into  a  subcutaneous  vein  of  an  animal,  provoke  inflam- 
matory foci  first  in  the  lungs,  where  the  veins  deposit  the  larger  par- 
ticles ;  next  in  the  joints  —  in  young  animals  in  the  bone  marrow ;  then 
in  the  periosteum  and  the  kidneys ;  and  last  in  the  liver  and  serous 
cavities.  Other  organs,  including  the  muscles,  the  myocardium,  sub- 
cutaneous tissues,  etc.,  are  involved  only  when  large  quantities  of  bac- 
teria are  injected.  This  selective  characteristic  on  the  part  of  certain 
organs  is  anatomical,  as  far  as  embolic  deposits  are  concerned,  and  also 
may  be  attributed  to  the  fact  that  certain  organs  (spleen,  bone  mar- 
row) develop  hactericidal  substances,  which  extract  the  excitants  from 
the  blood  current  and  destroy  them  when  they  are  not  too  virulent 
or  present  in  too  great  numbers. 

The  clinical  picture  of  metastatic  infection  is  (excluding  the  crypto- 
genic cases)  PRECEDED  BY  THE  SYMPTOMS  OF  A  GENERAL  INFECTION  DUE 
TO  AN  INFECTED  WOUND,  OR  THE  PRESENCE  OF   A  LOCAL  INFLAMMATORY 

FOCUS.  The  fever,  which  may  have  been  remittent  or  continued  as  the 
outcome  of  the  absorption  attendant  upon  the  original  lesion,  is  inter- 
rupted by  a  chill  and  followed  by  a  sharp  exacerbation  of  tempera- 
ture. However,  this  need  not  necessarily  be  regarded  as  a  determin- 
ing  indication   of  general   infection,    even  though   the   presence   of 


GENERAL  PYOGENIC  INFECTIONS  335 

bacteria  may  be  demonstrated  in  the  blood.  The  clinical  picture  must 
be  attended  hy  the  coexistence  of  a  numher  of  symptoms,  before  the 
diagnosis  of  general  infection  in  one  of  its  forms  can  he  established. 

Metastatic  infection  is  characterized  by  severe  chills,  peculiar  febrile 
movement,  grave  constitutional  disturbances,  and  the  appearance  of 
metastases. 

The  initial  chill  is  usually  very  severe;  this  may  be  followed  by 
chills  several  times  each  day,  or  at  intervals  of  several  days. 

Each  chill  is  followed  by  a  sharp  rise  of  temperature  40°-41°C. 
(104°-105.8°F.). 

As  the  temperature  falls  each  morning  (three  to  four  degrees)  and 
frequently  rises  again  after  another  chill,  the  fever  curve  is  remit- 
tent in  character.  Although  this  is  the  rule  in  cases  of  metastatic 
infection,  it  is  not  invariably  so,  the  fever  becoming  constant  when 
one  or  more  metastatic  foci  furnish  pyogenous  substances  in  exces- 
sive quantity,  or  when  the  protective  capacity  of  the  body  becomes 
exhausted. 

Without  the  presence  of  other  corroborative  manifestation,  the  pres- 
ence of  the  remittent  tyje  of  fever  may  not  be  regarded  as  diagnostic 
of  metastatic  infection,  for  simple  absorption  fever  (unwisely  desig- 
nated as  septic  fever  by  some  authors)  may  be  attended  with  a  similar 
fever  picture,  especially  when  the  focal  inflammation  is  due  to  strepto- 
coccus infection. 

This  is  also  true  of  continued  absorption  fever.  Even  though  the 
presence  of  bacteria  in  the  blood  is  demonstrated,  the  absence  of  other 
s3^mptoms  of  metastatic  infection  justifies  ascribing  fever  of  this  sort 
to  the  reaction  provoked  by  the  absorption  of  toxic  substance  from 
the  local  inflammatory  focus. 

Variations  in  febrile  movement  are  no  doubt  provoked  by  different 
classes  and  strains  of  bacteria,  but  these  are  not  susceptible  of  clinical 
differentiation. 

The  systemic  disturbances  are  those  of  a  severe  acute  infectious 
disease,  malaise  is  profound,  joint  pain  is  acute,  the  pulse  and  respira- 
tion are  much  accelerated,  the  tongue  is  dry,  thirst  is  marked,  the 
skin  dry  and  hot  or  bathed  in  perspiration,  headache  is  severe, 
delirium  and  subconsciousness  occur  early,  and  vomiting  is  persistent. 

To  this  symptom  complex,  is  added  severe  diarrhea  which  also 
occurs  in  non-metastatic  general  infection,  and  may  be  eliminative 
(an  effort  to  get  rid  of  the  toxins)  or  may  be  due  to  embolic  inflam- 
mation of  the  mucosa  of  the  gut;  the  development  of  icterus  which 


336  INFECTIONS  OF  WOUNDS 

often  makes  its  appearance  in  three  or  four  days  and  is  ascribed  to  the 
destruction  of  red  blood  corpuscles  (hemocytolysis)  ;  acute  enlarge- 
ment of  the  spleen,  as  is  common  to  all  infectious  diseases  but  may  be 
due  to  metastatic  abscesses;  Mood  changes  consisting  of  hemocytolytic 
lessening  of  red  blood  corpuscles  and  leukocytosis ;  and  ulcerative  endo- 
carditis which,  according  to  Lenhartz,^  occurs  in  one  fifth  to  one 
fourth  of  the  cases  of  general  infection,  but  most  frequently  attends 
the  metastatic  form  of  the  disease,  and  attacks,  by  preference,  the  left 
heart. 

The  seat  of  localization  of  a  metastatic  inflammation  provokes 
especial  symptoms  indicative  in  this  connection,  which,  of  course, 
present  exceedingly  varied  clinical  pictures. 

"When  metastatic  abscesses  and  purulent  infiltration  of  the  lungs 
dominate  the  picture,  the  general  symptoms  are  supplemented  (aside 
from  the  physical  signs)  by  dyspnea,  cough,  expectoration  and,  when 
the  process  persists,  by  evidences  of  pleuritis,  the  latter  being  indica- 
tive of  peripheral  lung  foci.  Pulmonary  infarcts  are  evidenced  by 
sudden  dyspnea,  syncope,  heart  failure,  and  bloody  sputum. 

Kidney  involvement  may  not  give  evidence  of  its  presence,  or  it 
may  take  on  the  character  of  severe  acute  nephritis.  The  invaded 
kidney  substance  presents  a  number  of  minute  infarct  like  foci  in  its 
cortex  and  long  streaky  deposits  in  its  parenchyma.  The  latter  are 
due  to  the  migration  of  bacteria  which  accumulate  in  the  glomeruli  and 
infiltrate  the  urinary  tubules. 

Joints,  especially  the  larger  ones,  are  usually  sequentially  involved 
either  acutely  or  subacutely,  the  process  varying  from  serous  to  puru- 
lent synovitis,  which  in  severe  cases  extends,  and  takes  on  the  form  of 
destructive  arthritis.  At  times,  the  joint  metastases  are  accompanied 
.(especially  in  gonococcic  infection)  by  inflammation  of  tendons  and 
bursae. 

The  eyes  are  frequently  the  seat  of  hemorrhages  and  necrosis  of  the 
choroid,  clouding  of  the  vitreous  and  purulent  iridochoroiditis  and 
panophthalmia. 

The  serous  memhranes  are  invaded  by  way  of  the  blood  current, 
especially  by  strepto-  and  pneumococci,  or  are  affected  by  extension 
from  foci  in  contiguous  organs,  the  brain,  the  lungs,  the  myocardium, 
and  the  abdominal  organs.  In  rare  instances,  the  tunica  vaginalis  is 
involved  (empyema)  by  extension  from  a  focus  in  the  testicle  or 
epididymis. 


GENERAL  PYOGENIC  INFECTIONS  337 

Muscle  foci  are  either  circumscribed  or  diffuse,  are  often  due  to 
staphylococcus  infection,  and  are  likely  to  be  widely  distributed. 

Subcutaneous  foci  are  exceedingly  numerous,  and  are  either  pri- 
mary or  the  result  of  extension  from  the  deeper  tissues.  Per  contra, 
the  muscles  are  likely  to  be  invaded  by  the  extension  of  subcutaneous 
abscesses. 

The  skin  is  visited  by  metastatic  erj-sipelas  or  the  appearance  of  a 
rash  not  unlike  that  of  scarlatina,  or  it  may  be  the  seat  of  small 
hemorrhages  and  herpetic  pustules. 

The  relationship  metastases  bear  to  the  primary  focus  varies,  being 
either  secondary  to  it  or  tertiary;  in  the  latter  event,  they  are 
derived  from  a  secondary  focus.  This  is  common  in  cases  of  ulcera- 
tive endocarditis. 

The  course  of  metastatic  infection  is  acute  or  chronic.  "When  the 
acute  form  is  attended  with  a  number  of  metastatic  foci,  and  additional 
areas  are  invaded  despite  radical  treatment  of  the  primary  zone  of 
infection,  a  fatal  termination  follows  in  a  short  period  of  time.  The 
more  numerous  the  infected  areas,  the  greater  is  the  likelihood  of  the 
development  of  a  chronic  condition,  each  focus  of  which  gives  rise  to 
toxic  substances  that  are  fed  into  the  circulation. 

The  chronic  form,  at  times  observed  in  connection  with  staphylo- 
coccus infection,  drags  on  for  many  weeks  and  months,  and  even 
though  numerous  abscesses  in  the  skin,  muscles,  and  joints  heal,  the 
activities  of  the  infection  continue  in  important  organs. 

The  outlook  in  acute  cases  is  unfavorable,  as  it  also  is  in  involvement 
of  organs;  however,  when  the  metastases  are  confined  to  accessible 
parts  recovery  may  occur. 

Recognition  of  the  diseases,  when  clearly  defined,  is  not  difficult. 
In  the  so-called  cryptogenic  cases  which  originate  in  internal  organs, 
confusion  arises  in  connection  with  acute  suppurative  nephritis,  cere- 
brospinal meningitis,  and  acute  articular  rheumatism  complicated  by 
endocarditis.  Cases  beginning  insidiously  may  simulate  acute  miliary 
tuberculosis  and  tj-phoid  fever. 

The  most  important  diagnostic  measures  are  the  examination  of  the 
exudate  of  the  metastases  and  the  Mood  for  bacteria  (p.  225).  Bac- 
teria may  often  be  discovered  in  the  blood  immediately  after  the 
initial  chill.  The  presence  of  pyogenic  excitants  in  the  blood  excludes 
acute  articular  rheumatism  from  consideration    (Lenhartz*). 

The  treatment  of  metastatic  infection  should  be  directed  toward  the 
prevention  of  its  spread  by  way  of  the  blood  current.     This  is  often 


338  INFECTIONS  OF  WOUNDS 

accomplished  by  free  exposure  and  drainage  of  the  primary  focus 
(p.  239)  or  by  removal  of  the  afflicted  part,  by  amputation  of  a  limh, 
excision  of  a  joint,  or  extirpation  of  an  organ.  At  times,  tlie  advance 
of  the  process  by  means  of  thrombophlebitis  may  be  checked  by  liga- 
ture of  the  main  trunks  of  veins,  such  as  the  internal  jugular,  in  otitis 
media ;  the  facial,  in  carbuncle  of  the  face ;  and  the  saphenous  in 
infections  of  the  legs  (see  phlebitis  purulenta). 

The  secondary  foci  should  be  promptly  opened  and  drained. 

The  general  condition  should  be  sustained  by  light,  supporting  diet, 
the  administration  of  cardiac  stimulants,  the  introduction  of  sodium 
chlorid  solution  and  blood  transfusion  (see  General  Treatment  of  Blood 
Infection,  p.  239). 

B.  PYOGENIC  GENERAL  INFECTION  WITHOUT  METASTASES 
{Non-Metastatio  Infection) 

The  non-metastatic  form  of  infection  is  characterized  by  the  pres- 
ence in  the  entire  organism  and  circulation  of  an  overwhelming  quan- 
tity of  bacteria  and  bacterial  toxins,  attended  with  rapid  multiplica- 
tion of  the  former.  This  condition  of  affairs  is  established  when  the 
protective  capacity  of  the  body  is  at  low  ebb  or  exhausted,  and  when 
the  aggressors  possess  a  high  degree  of  virulence. 

The  provocative  factors  favoring  the  development  of  this  phase  of 
infection  are  similar  to  those  of  the  metastatic  form,  except  that  em- 
bolic dissemination  is  absent,  and  that  a  preliminary  primary  inflam- 
matory focus  may  fail  to  be  established.  Omission  of  the  defensive 
activities  of  the  latter  makes  possible  the  almost  simultaneous  appear- 
ance of  the  grave  sj^stemic  manifestations  and  local  reaction,  and 
accounts  for  the  rapid  occurrence  of  a  fatal  outcome. 

Among  the  provocative  excitants,  streptococcus  pyogenes  is  the  one 
most  frequently  resposible  for  this  form  of  infection.  It  enters  the 
circulation  not  only  from  inflammatory  areas,  but  is  often  present  in 
putrid  wound  infections,  an  environment  which  seems  to  enhance  its 
virulence.  Staphylococci,  pneumococci,  colon  bacilli,  etc.,  are  less 
often  the  cause  of  severe  forms  of  general  infection,  though  fibrinoua 
pneumonitis  is,  at  times,  complicated  in  this  way.  When  mixed  infeC' 
tions  occur,  the  streptococcus  is  usually  the  one  that  finds  its  way  into 
the  circulation  and  is  responsible  for  the  grave  systemic  aspects  of  the 
situation. 

Pyogenic  general  infection  is  mostly  bacterial  in  character,  that  is, 


GENERAL  PYOGENIC  INFECTIONS  339 

the  circulation  is  impregnated  with  rapidly  multiplying  organisms  that 
produce  toxins  in  large  quantities.  "When  in  the  presence  of  a  clinical 
picture  of  grave  systemic  poisoning,  repeated,  carefully  executed, 
blood  examination  fails  to  reveal  bacteria,  and  the  local  inflammation 
is  shown  to  be  purely  pyogenic  in  character,  it  is  justifiable  to  conclude 
that  the  case  is  one  of  toxic  general  infection,  a  condition  which  is 
the  rule  in  putrid,  and  the  exception  in  pyogenic  infections. 

The  onset  of  the  illness  is  expressed — frequently  only  a  few 
hours  after  receipt  of  a  seemingly  unimportant  lesion  —  by  a  chill, 
high  fever,  and  severe  systemic  disturbances  (especially  after  injuries 
received  at  autopsies  upon  cadavers  recently  dead  of  general  pyogenic 
infection)  ;  or  it  may  develop  gradually  after  prolonged  absorption 
of  the  products  of  a  local  inflammator}^  process  (phlegmon,  peritonitis, 
arthritis,  osteomyelitis,  etc.),  in  which  instance,  the  general  infection 
occurs  without  the  sudden  appearance  of  a  sharply  defined  group  of 
sj'mptoms. 

The  clinical  picture  is  made  up  of  the  collective  symptoms  of  the 
gravest  possible  nature,  indicating  a  severe  systemic  disease.  The 
fever  is  continued  in  character,  the  remissions  being  rarely  more  than 
one  half  to  one  degree.  Before  death,  collapse  is  attended  with  sub- 
normal temperature. 

The  other  symptoms  begin  with  malaise,  cramp-like  pains  in  the 
extremities,  nausea,  vomiting,  and  acceleration  of  the  pulse  and  respi- 
ration, all  of  which  soon  merge  into  disturbances  of  the  sensorium  — 
headache,  delirium,  coma,  and  stupor.  The  skin  is  dry  and  hot,  the 
longue  dry,  the  lips  cracked,  thirst  is  marked,  the  urine  concentrated 
and  albuminous;  bloody  diarrhea  develops,  the  surface  of  the  body 
becomes  cyanotic  and  icteric,  presenting  scarlatina-like  and  urticarial 
rashes,  and  exhibits  small  pustules  and  petechial  hemorrhages  due  to 
diapedesis  or  rupture  of  small  blood  vessels.  The  spleen  becomes  en- 
larged and  the  bladder  and  rectum  are  emptied  involuntarily.  Bed 
sores  develop  over  the  sacrum,  the  trochanters,  and  at  the  heels. 
Finally,  the  heart  weakens  and  death  occurs  from  exhaustion. 

The  appearance  of  the  wound  is  characteristic.  Irrespective  of  the 
nature  (incised  or  lacerated)  of  the  wound,  its  surfaces  are  dry  and 
discolored,  as  the  result  of  superficial  necrosis  and  the  presence  of 
fibrinous,  bacteria  infested  exudate.  The  tissues  contiguous  to  the 
wound  are  no  longer  capable  of  secreting  pus,  nor  of  producing  granu- 
lations. 

Coincident  simple  fractures  undergo,  at  times,  slight  suppuration. 


340  INFECTIONS  OF  WOUNDS 

The  blood  changes  consist  of  a  striking  reduction  in  the  number  of 
red  corpuscles  (at  times  90  per  cent),  and  of  hemaglobin  content. 
The  blood  is  also  markedly  thinned  as  a  result  of  the  loss  of  albumin. 
Leukocytosis  is  not  present.  Abnormal  permeability  of  the  blood 
vessels  leads  to  hemorrhages  under  the  skin,  in  the  serous  cavities, 
under  the  conjunctiva  and  rectum,  and  into  the  bone  marrow  (hemor- 
rhagic general  infection). 

In  the  so-called  transitional  forms,  the  clinical  picture  is  rendered 
less  clearly  defined  by  the  occurrence  of  metastases  in  the  course  of 
blood  infection. 

The  duration  of  the  disease  is  usually  brief.  In  severe  cases,  death 
ensues  at  the  end  of  one  or  two  days  (especially  in  prolonged  infection). 
The  systemic  manifestations  frequently  improve  after  incision  and 
drainage  of  the  local  process,  amputation  of  a  limb,  etc.,  but  are 
reasserted  at  the  end  of  a  few  more  days.  When  the  condition  is 
once  fully  established,  recovery  is  rare. 

Recognition  of  completely  developed  cases  is  not  difficult.  Repeated 
blood  examinations  clear  up  doubt  with  respect  to  typhoid  fever  and 
miliary  tuberculosis.  Ditferentiation  between  scarlatina  with  sec- 
ondary streptococcus  infection  and  general  streptococcus  infection 
with  a  scarlatina-like  exanthematous  eruption  is  attended  with  some 
difficulty. 

During  the  initial  stage  of  general  infection,  the  diagnosis  is  not 
based  on  the  blood  findings,  but  rests  upon  the  severity  of  the  general 
symptoms;  it  is  not  alwaj^s  easily  differentiated  from  the  disturbances 
due  to  the  absorption  of  toxic  elements  from  local  inflammatory  pro- 
cesses. Clinical  experience  is  a  valuable  asset  in  this  connection. 
Daily  hematological  examinations  are  of  great  diagnostic  value.  The 
appearance  of  the  wound  is  also  helpful.  Failure  of  leukocjiiosis  is  of 
grave  prognostic  import. 

Pyogenic  and  putrefactive  general  infections  do  not  present  any 
clinical  differences  as  regards  the  systemic  symptoms.  Locally,  the 
appearance  of  the  latter  is  characteristic  enough,  though  it  must  be 
remembered  that  streptococcus  infection  frequently  emanates  from 
putrefactive  local  foci. 

The  prophylactic  treatment  relates  to  early  incision  and  drainage, 
or  amputation,  resection,  or  excision  of  the  part  primarily  invaded. 
These  measures  must,  however,  be  employed  early  in  the  disease  to 
afford  relief. 

In  addition  to  this,  the  treatment  is  directed  toward  palliation  of 


GENERAL  PYOGENIC  INFECTIONS  341 

the  symptoms ;  pain  and  delirium  are  controlled  by  opiates.  General 
resistance  is  maintained  by  the  administration  of  light,  nourishing 
food;  and  the  heart's  action  is  supported  by  cardiac  stimulants.  The 
introduction  of  saline  solution  by  various  means  (p.  51)  is  perhaps 
the  most  useful  measure  we  possess  for  the  purpose  of  lessening  the 
toxemia  and  sustaining  the  vital  forces. 

Serum  treatment  has  not,  so  far,  proved  of  value,  nor  has  the  intro- 
duction into  the  circulation  of  disinfectants,  like  corrosive  sublimate 
and  the  silver  preparations,  been  helpful  (Brunner,^  Cohn^). 

BIBLIOGRAPHY 

1.  Lexer.    Allg.  Chir.  i,  Stuttgart,  1914. 

2.  GussENBAUER.     Deutscli.  Chir.  Stuttgart,  1882,  with  lit. 

3.  Bruxxer.     Frankfort,  1899. 

4.  Lexhartz.     Nothnagel's  Spec.  path,  etc.,  Wien,  1903,  with  lit. 
o.  v.  Wassermaxx.     Same  as  No.  4. 

6.  v.  Kahldex.     Zentrbl.  f.  Pathol,  1902. 

7.  BOXDT.     Ersebn.  d.  Chir.  u.  Orthop.  Bd.  7,  1913. 

8.  Bruxxer.     Fortschr.  d.  Med.,  1900,  Ko.  20. 

9.  CoHX.    Konigsberg,  1902. 


CHAPTER  XII 

THE   PUTREFACTIVE    INFECTIONS 

PUTREFACTIVE  WOUND  INFECTION  AND  GENERAL  INFECTION 

Putrefactive  infection  of  a  wound  is  characterized  by  an  infiltra- 
tion of  its  surface  and  the  tissues  contiguous  to  it  by  a  primarily  sero- 
hemorrhagic exudate,  which  soon  forms  a  fetid,  gaseous,  gangrenous 
mass.  This  process  is  attended  by  clinically  allied  conditions,  in 
which  either  the  formation  of  gas  {gas  yklegmon),  or  gangrenous 
destruction  {noma)  dominates. 

Areas  of  putrefactive  infection  are,  however,  frequently  invaded  by 
pyogenic  bacteria  (especially  streptococci),  the  result  of  which  is, 
that  the  clinical  picture  is  one  of  mixed  infection.  When,  under  these 
conditions,  general  (systemic)  infection  develops,  the  presence  of 
streptococci  in  the  blood  gives  to  the  disease  the  appearance  of  a 
purely  pyogenic  invasion;  however,  the  severity  of  the  constitutional 
manifestations  leaves  no  doubt  that  the  absorption  of  the  pro- 
ducts of  putrefaction  plays  an  important  part  in  the  process.  General 
infections,  provoked  simultaneously  by  putrid  and  pyogenic  poisoning, 
might  quite  properly  be  designated  by  the  term  " pyosepthemia," 
were  it  not  for  the  reasons  already  stated  (p.  332).  Under  the  circum- 
stances, it  would  seem  best  to  employ  a  terminology  consistent  with  the 
character  of  the  process  dominantly  manifested  at  the  port  of  entrance 
of  the  infection.  When  the  local  process  is  essentially  putrid  in 
character,  the  term  "putrefactive  general  infection"  may  be  used, 
even  though  streptococci  are  present  in  the  blood ;  and  when  the  local 
focus  presents  the  characteristics  of  purulent  inflammation,  the  term 
**  general  pyogenic  infection  "  may  be  used,  even  though  putrefac- 
tive organisms  are  found  at  the  port  of  entrance. 

The  bacilli  of  the  colon  group  produce  conditions  which  at  one  time 
resemble  the  pyogenic,  and  at  another  the  putrid  forms  of  infection. 

Putrefaction  bears  a  close  resemblance  to  fermentation,  the  former 
being  a  reduction  process,  while  the  latter,  like  that  of  cadaveric  decay, 
is  dependent  upon  oxidation.     The  action  of  anaeroMc  bacteria  upon 

342 


THE  PUTREFACTIVE  INFECTIONS  343 

nitrogenized  substances  (especially  albumin)  is  to  split  them  into 
bodies  of  simpler  chemical  composition,  a  portion  of  which  gives  rise 
to  foul  odors.  In  this  process,  carbon  dioxid,  hydrogen,  sulphurated 
hydrogen,  ammonia,  and  other  stinking  gases  are  given  off,  and  certain 
complex,  poisonous  and  nonpoisonous  bodies  —  the  so-called  putre- 
factive alkaloids  (ptomaitis)  and 2)oisonous  albuminoids  {toxalhumins) 
—  are  formed. 

Nencki  (1876)  is  credited  with  having  been  the  first  observer  who 
succeeded  in  isolating  a  ptomain ;  however,  the  work  of  Brieger  (1885- 
1886)  may  be  regarded  as  having  established  the  real  character  of 
this  class  of  poisons,  to  which  he  gave  the  name  of  toxins,  though  this 
is,  at  the  present  time,  applied  only  to  the  poisonous  substances  de- 
veloped in  connection  with  bacterial  infections. 

The  chief  excitants  of  putrid  wound  infection  belong  to  extensive 
groups  of  bacteria,  of  which  the  proteus  bacillus,  the  color,  'bacillus,  the 
bacterium  emplujscmatosum,  and  the  edema  bacillus  are  the  most 
important.  To  these  may  be  added  gas  producing  staphylo-  and 
streptococci  ( Schottmiiller^ ) . 

Of  the  larger  group  of  facultatively  anaerobic  proteus  bacilli,  the 
proteus  vulgaris  (Hauser^)  is  the  most  important, 

1.  The  bacillus  proteus  vulgaris  is  1.2-4  microns  in  length  and  at  its 
middle  0.6  microns  in  breadth,  it  possesses  numerous  flagella,  is  actively 
motile,  and  is  not  readily  stained  by  Gram. 

The  bacillus  grows  on  gelatin  which,  under  aerobic  conditions,  it 
liquefies,  causing  the  development  of  stinking  substances,  indol,  sul- 
.  phurated  hj^drogen,  etc.  Under  complete  anaerobiosis,  the  growth  is 
the  same,  but  the  gelatin  is  not  liquefied.  Glucose  in  culture  media  is 
fermented  and  gas  is  given  off;  urea  is  decomposed  into  carbonate  of 
ammonia. 

The  most  characteristic  growth  occurs  on  gelatin,  where  the  bacilli 
grow  rapidly,  causing  the  formation  of  tiny  pools  filled  with  a  white 
mass  in  which  they  move  with  considerable  activity.  The  small  pools 
are  surrounded  by  radiating  streaks  of  liquefied  media  in  which  the 
bacilli  rapidly  multiply. 

The  culture  growth  of  the  bacillus  is  attended  with  the  formation 
of  an  alkaloidal  poison,  which  E.  Levy^  considers  identical  with  the 
sepsin  of  v.  Bergmann  (1868),  though,  according  to  Fomet  and 
Heubner'*,  the  mode  of  its  development  has  not  yet  been  cleared  up. 
Seitz^  considers  the  action  of  the  poison  as  similar  to  that  of  anaphy- 
latoxin. 


344  INFECTIONS  OF  WOUNDS 

Experimental  subcutaneous  injection  provokes  abscess  formation; 
the  intravenous  is  followed  by  toxic  symptoms  and  purulent  metas- 
tases. The  bacillus  seems  to  multiply  in  living  tissue  only  when  this 
is  damaged  or  ha^  become  necrotic  as  the  result  of  the  action  of  other 
bacteria;  per  contra,  the  viability  of  the  proteus  in  tissues  is  at  times 
essential  to  the  pathogenesis  of  other  bacteria,  such  as  the  strepto- 
coccus, the  colon  bacillus,  etc. 

As  the  bacillus  is  indigenous  to  the  habitat  of  the  human,  and  is 
normally  present  in  the  feces,  it  is  understandable  why  it  gains  access 
TO  neglected  wounds  and  ulcers. 

The  proteus  may  be  found  in  the  stinking  gangrenous  foci  and 
putrid  phlegmonous  processes  in  man,  where  it  is,  however,  rarely 
the  sole  bacterial  excitant ;  it  may  also  be  found  in  the  blood  and  in 
the  organs.  Usually,  it  invades  the  body  together  with  colon  bacilli 
and  streptococci;  and  thus  the  clinical  picture  of  general  infection 
they  are  concerned  in  producing  is  influenced  to  no  small  extent  by 
the  excitants  associated  with  them. 

As  the  proteus  vulgaris  is  often  associated  with  the  communis  coli 
in  putrid  animal  substances  (v.  Ermengen"),  the  ingestion  of  foul 
meat  may  introduce  the  former  into  the  gastro-intestinal  canal,  and 
give  rise  to  pathogenesis,  either  by  its  multiplication  or  as  the  result 
of  the  poisons  it  has  caused  to  develop  in  the  meat.  This  condition 
usually  ends  in  spontaneous  recovery  in  contradistinction  to  the  genu- 
ine botulism  (sausage  poisoning  due  to  the  bacillus  botulinus)  which 
often  terminates  fatally.  Wesenberg^  was  able  to  cultivate  a  proteus 
bacillus  from  putrid  meat  which  had  caused  acute  gastrointestinal  dis- 
turbance in  sixty-three  cases. 

The  proteus  is  also  found  associated  w^ith  the  communis  coli  in 
wounds,  fistulae,  and  abscesses  near  the  anus  which  have  been  contam- 
inated by  fecal  matter.  It  often  invades  the  urethra  and  bladder, 
extending  at  times  to  the  pelvis  of  the  kidney  (cystitis  and  pyelone- 
phritis—  especially  after  catheterization),  or  gains  access  to  the 
female  genitals,  where  it  plays  as  important  a  part  in  puerperal  gen- 
eral infection  as  does  the  streptococcus  in  its  association  with  the 
communis  coli  in  cases  of  peritonitis  due  to  intestinal  perforation. 

The  bacillus  at  times  enters  the  gall-bladder  from  the  gut,  and  has 
been  found  in  the  blood  and  in  the  large  organs. 

2.  The  bacilli  of  the  colon  group  (bacterium  coli  communis)  have 
already  been  discussed  under  the  head  of  pyogenic  excitants,  for  the 


THE  PUTREFACTIVE  INFECTIONS  345 

reason  that  they  are  largely  concerned  in  the  pathogenesis  of  local  and 
general  purulent  inflammatory  processes. 

The  bacillus  is  often  found  associated  with  the  proieus  vulgaris  in 
Avound  infections  following  contamination  with  fecal  matter;  in  peri- 
tonitis due  to  intestinal  perforation;  and  in  cases  of  meat  poisoning 
(see  proteus).  It  frequently  coexists  with  pyogenic  bacteria  in  putre- 
factive foci.  It  has  been  found  to  be  the  sole  excitant  in  cases  of  gas 
phlegmon. 

"Why  some  cases  exhibit  the  characteristics  of  purulent  infection 
and  others  develop  stinking,  putrid  foci  attended  with  gangrene  and 
th6  formation  of  gas  is  not  clear.  It  is  probably  not  bacause  of  the 
kind  of  colon  bacillus  present,  but  would  seem  to  depend  upon  the 
coexistence  of  other  excitants,  such  as  the 
proteus  group  which  is  frequently  present  in 
fecal  infections. 

3.  The  bacillus  emphysematosus  (bacil- 
lus aerogenes  capsulatus,  Fig.  140)  was 
found  by  E.  FraenkeP  (1893)  in  four  cases 
of  gas  phlegmon ;  in  three  of  these  the  bacil- 
lus was  associated  with  other  (pyogenic) 
bacteria,  and  in  one  was  the  sole  excitant. 

From  the  last  Fraenkel  derived  the  cultures 

,  .       ,  4-  1      J         -u     •+  Fig.     140.— Bacillus     Em- 

permittmg  him  to  accurately  describe  it.  physematosus. 

Welch  and  NuttalP  in  1892  described  the    ,^  „  ,  ,„    .„      ... 

(Kelly)    (Bacillus  Aerogenes 

bacterium    under    the    name    of    aerogenes  Capsulatus). 

capsulatus.    Later  it  was  shown  that  Fraen- 
kel's  emphysematosum  was  identical  with  it.    A  number  of  observers 
have  described  bacteria  similar  to  this  one  under  various  names. 

Hiss  and  Zinsser^^  state  that  *'we  are  probably  dealing  with  a  group 
of  bacilli  of  which  certain  strains  possess  morphological  characteris- 
tics not  sufficiently  distinctive  to  permit  of  differentiation."  They 
describe  the  bacterium  as  a  large.  Gram  positive,  nonmotile  organism, 
with  rounded  ends,  rarely  occurring  in  chains,  and  aerobic.  Spore 
formation  is  inconstant  and  occurs  only  in  alkaline  medium.  Capsules 
may  be  seen  in  smears  from  animals  but  are  missing  from  organisms 
taken  from  cultures. 

The  intravenous  injection  of  animals,  especially  rabbits,  leads  to  a 
non-suppurative,  necrotic,  inflammation,  attended  with  the  extensive 
formation  of  an  inodorous  gas  which  burns  with  a  pale  blue  flame. 
Foul  smelling  exudate  appears  in  the  presence  of  mixed  infection. 


346 


INFECTIONS  OF  WOUNDS 


A  true  exotoxin  has  not  yet  been  demonstrated.  Despite  carefully 
conducted  experimental  work  and  attentive  clinical  observation,  the 
exact  pathogenicity  of  the  bacterium  is  still  a  matter  of  doubt.  While 
it  "unquestionably  invades  the  human  body  and  does  much  harm  — 
may  even  be  the  direct  cause  of  death,  its  pathogenicity  would  seem 
to  depend  upon  its  association  with  either  trauma  or  with  other 
organisms  such  as  streptococci,  staphylococci,  etc.  This  makes  it 
understandable  why  severe  trauma  associated  with  contamination  of 
the  wound  with  soil,  as  obtains  in  connection  with  ''war  wounds," 

form  ideal  conditions  for 
the  production  of  bacillus 
emphyscmatosus  infec- 
tion. 

4.  The  iacillus  edema- 
tis  maligni  is  the  bac- 
terial excitant  of  malig- 
nant edema,  and  is  the 
most  important  organism 
concerned  in  producing 
this  condition  in  man. 

The  bacillus  was  first 
described  by  Pasteur"^^ 
under  the  name  of 
* '  vibrion  septique ' '  which 
he  obtained  in  an  impure 
state,  though  he  estab- 
lished its  anaerobicit}^  and 
its  chief  characteristic  in  connection  with  the  production  of  edematous 
inflammation.  Koch,^^  who  studies  this  infection  in  connection  with 
his  work  upon  anthrax  in  1881,  called  attention  to  the  fact  that  the 
bacillus  described  by  Pasteur  did  not  produce  a  true  ''septicemia" 
and  suggested  the  term  "bacillus  edematis  maligni"  which  is  now  in 
general  use. 

Gaifkyi^  found  that,  apart  from  its  appearance  in  putrid  material, 
the  bacillus  existed  in  the  upper  layers  of  garden  soil  and  in  dust. 
It  has  since  been  found  to  be  widely  distributed  in  nature  and  in  the 
intestines  of  hcrhivorous  animals.  Its  spores  are  extremely  resistant. 
The  bacillus  of  malignant  edema  (Fig.  141)  is  a  long,  slender  rod, 
not  unlike  the  anthrax  bacillus,  but  decidedly  more  slender.  Its 
average  measurements  are  one  micron  in  thickness  and  three  to  eight 


Fig.  141. —  Bacillus  of  Malignant  Edema. 


THE  PUTREFACTIVE  INFECTIONS  347 

microns  iu  length.  It  usually  occurs  in  single  rods,  but  frequently 
appears  in  long  threads  showing  irregular  subdivisions.  Often,  no 
subdivisions  are  discernible,  and  the  threads  appear  as  long,  homo- 
geneous filaments.  The  bacilli  are  motile  and  possess  numerous  later- 
ally placed  flagella.  It  produces  spores  at  temperatures  above  20  °C. 
(68°F.),  which  are  oval,  irregularly  placed,  either  in  the  center  or  at 
either  end,  and  cause  a  bulging  of  the  bacillary  body. 

It  is  readily  stained  by  any  of  the  usual  aniline  dyes  and  is  decolor- 
ized by  Gram. 

The  bacillus  edematis  maligni  is  strictly  anaerobic.  Under  anaerobic 
conditions  it  develops  rapidly  upon  any  of  the  usual  culture  media, 
m  all  of  which  it  forms,  by  the  cleavage  of  proteins,  putrid,  stinking 
gases  (Jensen^*). 

.  In  man  the  bacillus  is  found  in  the  dead  spaces  of  putrid  wounds, 
though  Jensen^*  found  it  in  the  mucosa  of  the  mouth.  Its  invasion  is 
attended  with  grave  constitutional  symptoms  and,  locally,  produces 
an  extensive  hemorrhagic  and  emphj'sematous  inflammation. 

Little  is  known  respecting  the  toxins  it  produces.  These  exist  only 
in  small  quantities,  and  j)roduce  a  negative  chcmotaxis  with  its  attend- 
ant retarding  effect  upon  leukocytosis;  it  does,  however,  provoke 
hyperemia  and  the  transudation  of  a  serous  exudate. 

The  development  of  putrid  infection  is  favored  by  the  presence  of 
devitalized  or  necrotic  tissue  in  deep  wounds  not  freely  accessible  to 
the  air.  It  is  also  probable  that  putrefactive  organisms  must  be  in 
consort  with  a  number  of  other  anaerobic  sapropJujtes.  The  virulence 
of  the  former  is  greatly  enhanced  by  the  simultaneous  presence  of 
streptococci  and  staph^'lococci.  Mixed  infection,  i.  e.,  the  coexistence 
of  proteus,  colon  bacilli,  and  streptococci  is  the  rule.  Mono-infection 
(bacillus  edematis  alone)  is  rare.  The  tetanus  bacillus  finds  favorable 
soil  for  its  activities  in  wounds  of  this  sort. 

Despite  the  fact  that  the  excitants  are  widely  distributed  in  nature, 
edogenous  putrefactive  infections  are  comparatively  rare.  This  is 
explained  on  the  ground  that  in  superficial  accidentally  inflicted 
wounds,  the  excitants  do  not  get  an  opportunity  to  develop,  and  in 
deep  wounds  such  as  compound  fractures,  laceration  by  machinery, 
etc.,  the  present  methods  of  thorough  cleansing,  drainage,  and  the  use 
of  dressings  which  do  not  entirely  prevent  the  entrance  of  air  also 
obviate  the  multiplication  of  anaerobic  bacteria.     Consequenth%  severe 

ECTOGENOUS  WOUND  INFECTION  OCCURS  ONLY  WHEN  SURGICAL  CARE  IS 

DELAYED.     Pucrpcral  putrid  infections  may  also  be  regarded  as  ecto- 


S48  INFECTIONS  OF  WOUNDS 

genous,  as  they  are  no  doubt  due  to  fertilization  of  the  female  genitals 
by  the  introduction  of  the  excitants  (colon  and  proteus  bacilli)  during 
vaginal  examinations. 

Endogenous  putrid  infections  are,  however,  not  so  infrequent. 
They  originate  in  the  mucosa  of  the  mouth,  gut,  and  urethra. 

In  the  cavity  of  the  mouth,  the  mucosa  is  often  the  site  of  circum- 
scribed, superficial,  putrid  and  gangrenous  infections  (stomatitis 
ulcerosa,  angina  gangrenosa,  pharyngeal  diphtheria,  etc.),  especially 
after  gunshot  wounds  of  the  mouth  attended  with  laceration  of  the 
tongue.  These  processes  take  on  the  form  of  putrid  phlegmonous 
inflammations  in  the  floor  of  the  mouth,  and  extend  downward  into 
the  loose  intermuscular  spaces  of  the  neck,  and  backward,  where  at 
times  edema  glottidis  develops.  Retropharyngeal  'phlegmon,  follow- 
ing injury  to  the  pharynx,  and  peri-esophageal  phlegmon,  due  to  a 
foreign  body,  perforation  of  carcinoma,  or  injury  by  the  esophago- 
scope,  extend  to  the  mediastinum  and  cause  death.  When  the  maxillae 
are  the  seat  of  putrid  inflammations  having  their  origin  in  the  putre- 
scent pulps  of  carious  teeth,  they  give  rise  to  alveolar  periostitis  which, 
fortunately,  usually  ends  in  spontaneous  recovery,  though  occasionally 
fatal  general  infection  ensues.  When  carcinomata  of  the  tongue  and 
larynx  become  massively  infested  wath  putrefactive  bacteria,  respira- 
tory aspiration  may  draw  fertilized  particles  of  dead  tissue  into  the 
lung,  causing  the  development  of  inflammatory  areas  which  soon 
undergo  gangrenous  degeneration.  GunsJiot  wounds  of  tire  lung,  and 
the  resultant  hemothorax,  are  very  likely  to  be  contaminated  by  bac- 
teria of  this  sort,  either  as  the  result  of  ectogenous  infection  introduced 
with  particles  of  clothing,  etc.,  or  by  aspiration  of  the  excitants.  The 
invasion  of  carcinomatous,  tuberculous,  and  syphilitic  ulcers  of  the 
larynx  by  putrefactive  bacteria  is  followed  by  the  development  of 
peritracheal  putrid  phlegmon. 

Perforation  of  the  gut  and  the  injury  it  causes  to  the  peritoneal 
endothelium  is  followed  by  acute,  progressive,  putrefactive  peritonitis 
and  fatal,  mostly  toxic,  general  infection,  the  result  of  the  activities 
of  intestinal  ferments,  bacteria,  and  bacterial  toxins  which  are  not 
encapsulated  by  the  protective  formation  of  adhesions,  therefore, 
remain  free  in  the  peritoneal  sac  (especially  proteus  and  colon 
bacilli  together  with  various  pyogenic  excitants).  Injury  to  the 
mucosa  of  the  rectum  by  sharp  particles  in  the  feces  often  gives  origin 
to  a  non-virulent,  circumscribed,  putrefactive  phlegmon  (ischiorectal 
abscess)  which  is  frequently  followed  by  fistula. 


THE  PUTREFACTIVE  INFECTIONS  349 

Injuries  to  the  urinary  bladder  and  urethra,  when  attended  ^A•ith 
infiltration  of  urine,  result  in  the  development  of  severe  gangrenous 
inflammation. 

Post  operative  endogenous  putrid  infection,  in  some  instances,  fol- 
lows surgical  attack  executed  in  the  region  of  the  colon  and  anus, 
especially  when  feces  gain  access  to  the  fresh  wound.  The  flaps  used 
in  plastic  repair  of  the  lip  and  cheek  are,  at  times,  invaded  b}^  putre- 
factive excitants  derived  from  the  mouth  and  become  gangrenous, 
especially  when  they  are  badly  nourished. 

Putrid  wound  infection  is  heralded  by  an  initial  chill  of  consider- 
able severity,  followed  by  a  sharp  febrile  movement,  and  characterized 
by  distinctive  local  manifestations.  The  wound  surfaces  are  dry  and 
give  off  an  offensive  odor.  Loose  strands  of  tissue  are  bluish  or  black 
in  color.  The  edges  of  the  skin  present  a  similar  appearance  and  are 
surrounded  by  a  zone  of  redness.  At  the  end  of  twenty-four  hours, 
scanty,  brown  or  greenish  brown,  stinking,  putrescent  fluid  oozes  from 
the  deeper  portions  of  the  wound,  while  the  contiguous  parts  are  more 
or  less  edematous,  red,  and  swollen.  Soon  the  surfaces  of  the  wound 
become  moist  and  large  areas  disintegrate  and  are  cast  off.  Pressure 
on  the  surrounding  surface  causes  the  formation  of  gas  bubbles  in  the 
wound  secretions. 

Favorahle  termination  of  the  process  is  preceded  by  gradual  reces- 
sion of  the  inflammator}'  swelling ;  the  flow  of  putrid  secretion  gradu- 
ally ceases,  and  granulations  progressively  dislodge  the  residual  gan- 
grenous areas  until  repair  is  accomplished. 

In  the  severe  cases,  general  infection,  attended  with  high  continuous 
fever,  rapidly  develops  and  presents  the  picture  of  a  menacing  pyo- 
genic blood  infection  which  results  fatally  in  from  twenty-four  hours 
to  a  few  days.  The  circulating  blood  frequently  contains  streptococci, 
less  often,  staphylococci  or  hacilli  coli,  and  has  been  known  to  contain 
the  proteus.  In  most  cases,  however,  the  blood  current  is  free  from 
bacteria,  but  is  the  more  richly  endowed  with  toxic  substances,  as  is 
shown  by  the  blood  changes. 

When  metastases,  which  are  usually  the  result  of  thrombo-embolic 
dissemination,  develop,  these  also  take  on  the  putrid  character  of  the 
original  focus. 

When  local  extension  occurs,  it  takes  on  the  form  of  a  phlegmonous 
inflammation,  attended  with  general  and  local  sj^mptoms,  the  severity 
of  which  exceed  even  the  virulent  form  of  streptococcals  infection. 
The  clinical  picture  of  putrid  phlegmon  is  indicated  by  the  names 


350  INFECTIONS  OF  WOUNDS 

given  it  by  the  older  observers,  sucli  as  acute  purulent  edema  with 
'putrescence;  progressive  gangrenous  emphysema;  gangrene;  fou- 
droyant  gangrene;  gangrenous  septicemia;  putrefactive  gangrene; 
panpMcgmonous  gangrene;  etc.  At  the  end  of  twenty-four  hours, 
the  afflicted  limb  is  often  inflamed  and  edematous,  presenting  red 
streaks  of  lymphangitis,  and  enlarged  painful  lymph  nodes,  while 
the  rapidly  increasing  infiltration  makes  pressure  on  the  circula- 
tion, causing  massive  swelling.  The  tense  skin  becomes  pale  and 
insensible,  large  blebs,  distended  M'itli  serosanguineous  fluid,  and  bluish 
black  areas  appear;  these  are  converted  into  black  crusts  and  are 
cast  off  in  the  form  of  gangrenous  patches.  Fluctuation  is  absent; 
on  the  other  hand,  digital  pressure  elicits  emphysematous  crackling, 
indicating  the  presence  of  gas  in  the  tissues.  The  fingers  and  toes  are 
pale  or  of  a  bluish  hue. 

When  putrid  infection  invades  a  wound,  the  phlegmonous  inflam- 
mation extends  to  the  deeper  tissues,  gradually  invading  the  muscles, 
the  periosteum,  and  the  bone,  and  converts  the  marrow  into  a  pulpous 
putrid  mass  (putrid  osteomyelitis).  The  joints  are  similarly  invaded, 
the  capsule  ruptures,  and  the  cartilages  are  separated  or  undergo 
disintegration. 

Incision  exposes  the  appalling  effects  of  the  infection.  The  edema- 
tous or  gangrenous  skin  is  found  separated  over  large  areas ;  the  sub- 
cutaneous tissue  consists  of  an  infiltrated  grayish  green  mass  filled 
with  air  bubbles ;  and  the  fascia  is  disintegrated  into  greasy  shreds. 
The  muscles  and  the  intermuscular  spaces  present  a  similar  picture, 
a  macerated  discolored  mass  from  which  pressure  elicits  putrid  fluid 
and  gas  bubbles.  .  The  periosteum  is  separated  from  the  bone  in  gan- 
grenous tatters,  and  putrid  ooze  wells  out  of  the  bone  medulla  through 
the  Haversian  canals.  The  subcutaneous  and  deeper  veins  are  filled 
wdth  putrid  thrombi,  and  the  walls  of  the  arteries  are  gray  and  friable 
or  eroded  (arteritis  gangrenosa),  giving  rise  to  violent  hemorrhage 
when  disturbed. 

Urinary  infiltration  of  the  abdominal  wall,  the  scrotum,  penis,  and 
perineum  is  attended  with  phlegmonous  inflammation,  which  follows 
extravasation  of  urine  from  a  traumatized  urethra,  or  one  perforated 
by  a  suppurative  process,  such  as  occurs  with  fracture  of  the  pubes, 
periurethritis  at  the  site  of  a  stricture,  and  injuries  received  from 
catheterization.  The  beginning  of  the  process  is  accompanied  b}^  rap- 
idly extending  swelling,  redness,  severe  pain,  and  fever,  and  later  is 
followed  by  extensive  gangrenous  disintegration  of  the  muscles,  the 


THE  PUTREFACTIVE  INFECTIONS  351 

fascia  and  skin,  provided,  of  course,  the  general  infection  does  not 
lead  to  an  early  fatal  outcome.  The  greater  the  number  of  excitants 
in  the  extravasated  urine,  the  more  severe  is  the  char-actcr  of  the 
infection  and  the  more  extensive  is  the  extent  of  the  destruction  of 
tissue. 

A  similar,  though  not  quite  so  menacing,  picture,  is  provoked  by 
the  entrance  of  feces  into  the  soft  parts,  as  occurs  after  gangrenous 
destruction  of  the  gut  in  strangulated  hernia  (fecal  phlegmon,  fecal 
abscess). 

As  necrotic  or  gangrenous  tissue  presents  favorable  soil  for  the 
colonization  and  rapid  multiplication  of  putrefactive  bacteria,  the 
development  of  putrid  infection  is  not  infrequent  wherever  necrosis 
occurs;  and  for  this  reason  the  "pressure  areas"  over  the  sacrum 
and  tuber  ischii  are  often  the  site  of  putrid  phlegmon  and  its  compli- 
cating genero^l  infection;  conditions  which  not  uncommonly  occur  in 
cases  of  tuberculous  fistulae  in  the  perineum  that  are  tampered  with 
by  ** rectal  specialists." 

Senile  gangrene  and  angiosclerotic  necrosis  of  the  fingers  and  toes 
with  dry  mummification  are  often  visited  by  putrefactive  excitants 
and  converted  into  putrid  infectious  processes,  giving  rise  to  the  devel- 
opment of  phlegmon.  At  times  a  similar  condition  of  affairs  appears 
in  connection  with  frozen  parts,  and  those  deprived  of  nourishment  by 
enibolic  ohstruction  or  neuropathic  disturhajices. 

Dialetic  gangrene  is  very  frequently  complicated  b}^  the  invasion 
of  pyogenic  and  putrefactive  bacteria;  this  is  understandable, 
considering  the  lessened  local  and  general  resistance  which  attends 
this  form  of  tissue  death.  So  it  is  not  uncommon  to  see  diabetic  gan- 
grene with  secondary  lymphangitis  and  phlegmon,  which  calls  for 
radical  methods  of  treatment,  including  amputation. 

The  prevention  of  putrid  infection  in  deep  lacerated  wounds  con- 
sists in  the  prompt  removal  of  tissue  shreds,  smoothing  the  edges  of 
the  superficial  wound,  loose  tamponade  and  drainage ;  in  other  words, 
the  opeii  treatment  of  the  ivound  is  to  be  employed,  a  measure  by  which 
secondary  infection  is  obviated.  In  the  presence  of  necrosis,  dry 
dressings  should  be  employed,  as  wet  dressings  favor  putrefaction, 
especially  in  diabetes. 

In  the  treatment  of  putrid  processes,  the  infected  tissue  is  widely 
incised,  dead  spaces  are  drained,  and  egress  for  the  contents  of 
abscesses  is  freel}^  established.  Tamponade  is  made  at  first  with  dry 
sterile  gauze.     Iodoform  gauze  should  not  be  used  at  this  time,  as  the 


352  INFECTIONS  OF  WOUNDS 

action  of  the  putrefactive  bacteria  decomposes  iodoform  into  sub- 
stances that  give  rise  to  poisoning.  When  gangrenous  patches  are 
present  upon  the  wound  surfaces,  or  when  the  skin  is  necrotic,  the 
use  of  unconfined  moist  dressings  aids  in  their  separation,  thus  per- 
mitting granulations  to  proliferate.  For  the  purpose,  mild  solutions 
such  as  aluminum  acetate,  borax,  etc.,  should  be  employed ;  antiseptics 
which  inhibit  cellular  growth  should  be  avoided. 

Amputation  is  a  measure  which  at  times  saves  life,  but  its  execution 
must  not  be  postponed  until  general  infection  is  dominantly  established. 

ALLIED  PROCESSES 

Gas  Phlegmon. —  This  is  a  term  applied  to  a  form  of  putrefactive 
phlegmon  characterized  hy  an  extraordinary  development  of  gas. 
The  skin  is  lifted  by  the  subcutaneous  accumulation  of  gas,  giving  the 
surface  of  the  body  the  appearance  of  an  air  cushion.  After  death, 
gas  is  disseminated  throughout  the  internal  organs  (so-called  "foam 
organs").  The  inflammatory  manifestations  are  dominated  by  those 
of  gangrene  (gas  gangrene). 

The  chief  provocative  excitants  seem  to  be  the  bacillus  emphj^sema- 
tosus  (FraenkeP)  and  allied  anacro'hics  (butyric  acid  bacilli — Welch,^ 
Stolz,^^  Koprac,^^  Rothfuchs,^'^  etc.).  Lenhartz^^  found  the  bacillus 
emphysematosus  in  the  blood  of  a  fatal  case  of  puerperal  general 
infection.  The  proteus,  the  communis  colt,  and  mixed  infection  with 
pyogenic  bacteria  also  are  frequently  present. 

Malignant  Edema. —  Malignant  edema  is  a  term  frequently  used  in 
connection  with  acute  purulent  and  putrid  infections,  but  it  should 
be  applied  only  to  putrid  and  gangrenous  phlegmonous  inflammations 
provoked  by  the  bacillus  edematis  maligni  alone,  or  in  association  with 
other  bacteria.  However,  even  bacterioscopic  examination  does  not 
always  clear  up  the  diagnosis  in  this  regard,  owing  to  the  similarity 
bacteria  of  this  sort  bear  to  each  other  (Gohn  and  Sachs^''). 

The  exudate  (before  putrefaction)  is  serous  and  deficient  in  cell 
content,  a  phenomenon  probably  ascribable  to  the  negative  chemotaxis 
of  the  bacterial  toxins.  A  similar  condition  of  affaii-s  obtains  in  gas 
phlegmon  not  complicated  by  coexisting  pyogenic  bacteria. 

The  treatment  of  gas  phlegmon  and  malignant  edema  is  the  same 
as  is  directed  toward  the  relief  from  putrefactive  infection. 

Noma  —  Cancrum  Oris  —  Gangrene  of  the  Cheek. —  Noma  is  a  gan- 
grenous process  closely  resembling  putrid  infections,  in  which  gan- 


THE  PUTREFACTIVE  INFECTIONS  353 

greiie  predominates.  It  attacks  the  checks,  the  lips,  the  gums,  the 
auditory  apparat-us,  and  adjacent  parts  of  the  face,  and,  at  times,  it 
invades  the  vulva  and  anus. 

The  disease  occurs  almost  exclusively  in  enfeebled  and  hadhj  nour- 
ished persons,  especially  in  children  between  two  and  twelve  years  of 
age  — ■  rarely  in  the  adult.  It  occurs  most  frequently  in  connection 
with  the  exhausting  effects  of  measles,  typhoid,  syphilis  (mercurial 
stomatitis),  diphtheria,  dysentery,  tuberculosis,  stomatitis  ulcerosa  of 
various  kinds,  malaria,  and  unhygienic  surroundings ;  all  of  which 
reduce  the  general  and  local  powers  of  resistance  and  furnish  favor- 
able soil  for  the  extension  of  parasitic  invasion. 

Noma  probably  is  not  communicable.  Its  appearance  in  epidemic 
form  is  no  doubt  due  to  the  spread  of  the  provocative  general  disea5:e, 
such  as  measles. 

Although  the  gangrenous  focus  literally  teems  with  bacteria  and 
fungi  —  which  is  quite  understandable  in  view  of  the  rich  bacterial 
flora  of  the  mouth  —  and  although  Perthes-"  and  Pawlowsky^^  have 
found  a  streptothrix  in  the  lesion  and  in  the  contiguous  tissues,  it  has 
not  been  possible  to  isolate  and  cultivate  a  specific  causative  organism. 
It  is  not  improbable  that  more  than  one  bacterial  excitant  may  be 
responsible  for  the  disease  (Hartog  and  Schiirman^^). 

Noma  begins  at  the  site  of  a  lesion  in  the  mucosa,  usually  (stomatitis 
ulcerosa)  in  the  cheek  near  the  corner  of  the  mouth;  at  times,  though 
not  freciuently,  it  begins  on  both  sides  or  on  the  gums  or  the  lips.  It 
appears  as  a  small  blister  filled  with  opalescent  fluid,  or  as  a  superficial 
ulcer  which  soon  takes  on  the  form  of  a  gangrenous  disintegration, 
extending  in  all  directions.  The  putrefactive  progression  is  sur- 
rounded by  a  rim  of  hard  infiltration. 

The  severity  of  the  process  is  indicated  by  high,  continued  fever  and 
disturbances  of  consciousness.  The  local  manifestations  consist  of  a 
massive,  though  not  particularly  painful,  swelling  of  the  cheek,  the 
skin  of  which  is  at  firsi  pale,  but  soon  becomes  blue  black  in  color; 
the  mucosa  is  infiltrated  to  a  corresponding  degree.  These  changes 
take  place  without  the  least  evidence  of  inflammatory  redness,  the 
chief,  and,  indeed,  the  distinguishing  characteristic  of  the  affliction. 
When  the  process  reaches  a  wide  expanse,  and  the  entire  face  and  side 
of  the  neck  swells,  a  moderate  degi-ee  of  inflammatory  reaction  may 
occur,  though  this  in  no  way  interferes  with  destructive  progression. 
In  a  few  daj^s  the  hlack  area  on  the  cheek  breaks  down,  as  does  the 
cheek  itself  and  the  mucosa  of  the  alveolar  processes,  the  teeth  loosen 


354 


INFECTIONS  OF  WOUNDS 


and  fall  out,  the  bones  are  denuded,  and,  in  severe  cases,  the  nose,  the 
tongue,  the  pharynx,  the  palate,  and  the  lip  undergo  gangrenous  dis- 
integration (Fig.  1-42)  ;  at  times  the  opposite  side  of  the  face  is 
invaded.  During  this  time  the  afflicted  area  discharges  a  vile  smell- 
ing, foul  mixture  of  saliva  and  putrid  liquid  which  flows  upon  the 
contiguous  surfaces  or  is  swallowed  and  provokes  vomiting,  or  it  may 
be  aspirated  into  the  lungs  and  give  rise  to  fetid  bronchitis,  pneumo- 
nitis, and  gangrene. 

Death  ensues  in 
seventy-five  per  cent  of 
the  cases  within  the  first 
week,  from  cardiac  para- 
lysis due  to  toxemia,  or 
is  caused  by  lung  com- 
plications. 

"When  recovery  oc- 
curs, the  gangrenous  tis- 
sues separate,  and  re- 
pair by  granulation 
takes  place.  Cicatriza- 
tion is  a  slow  process 
attended  with  much  loss 
of  substance,  and  is  fol- 
lowed by  grave  deformi- 
ties and  loss  of  function 
—  among  the  latter,  a 
locked  lower  jaw  is  not 
uncommon. 

For  the  purpose  of  re- 
lief, the  gangrenous  tis- 
sue should  be  removed 
with  the  actual  cautery. 

The  sloughing  cheek  may  first  be  sectioned  by  means  of  crucial  in- 
cisions which  make  more  accessible  the  parts  to  be  excised.  This  may 
be  supplemented  by  the  application  of  zinc  chlorid  or  acetic  acid  with 
the  view  of  limiting  further  extension  of  the  process. 

Measures  of  relief  must  be  promptly  executed.  The  use  of  saline 
infusion,  and  the  administration  of  alcohol  and  concentrated  articles 
of  diet,  together  with  cardiac  stimulants,  are  valuable  aids  in  the 
treatment. 


Fig,  142,— Noma, 
Despite   -wide   excision,   the   process  extended. 
Fatal  outcome  on  the  tenth  day. 


THE  PUTREFACTIVE  INFECTIONS  355 

The  resultant  deformities  are  subjected  to  various  plastic  methods 
of  repair. 

Hospital  Gangrene. —  The  term  hospital  (jangrcne  is  applied  to  an 
acute,  progressive,  putrefactive  wound  infection,  attended  with  tissue 
necrosis,  which  appeared  chiefly  in  hospitals  before  the  aseptic  era. 
At  that  time  the  infection  was  carried  from  bed  to  bed  by  the  mate- 
rials (especially  textile  fabrics)  used  for  dressings,  by  instruments, 
and  by  the  hands  of  the  attendants.  Epidemics  of  this  sort  were 
attended  with  an  appallingly  high  mortality,  especially  in  military 
hospitals  during  wartime. 

Hospital  gangrene  is  probably  caused  by  bacterial  invasion,  though 
this  has  not  been  proved.  Bacilli  have  been  found  in  the  gangrenous 
tissues  (Matzenavier-^),  but  isolation  and  pure  cultivation  has  not,  as 
yet,  succeeded.  In  one  instance,  Nasse"*  found  several  strains  of 
anaerobics. 

It  is  highly  probable  that  hospital  gangrene  is  a  putrid  infection 
which  may  be  due  to  various  bacteria,  including  those  responsible  for 
gas  phlegmon  and,  in  some  instances,  no  doubt,  the  diphtheria  bacillus 
is  responsible  for  the  condition.  Indeed,  it  is  doubtful  whether  the 
process  deserves  isolated  consideration ;  however,  retaining  it  in  the 
literature  at  least  accentuates  the  necessity  for  special  effort  in  the 
prevention  of  infection  in  connection  with  "war  wounds." 

Most  authors  divide  the  process  into  superficial  and  deep  forms 
(phagedena  superficialis  et  profunda  of  Koenig^'').  Delpech"*^ 
differentiates  an  ulcerative  and  a  pulpous  form. 

The  local  disorder  is  preceded  by  a  period  of  incubation  of  two  or 
three  days'  duration,  during  which  the  general  picture  of  an  infectious 
disease  is  presented.  On  the  third  day,  the  granulations  in  the  wound 
become  studded  with  small,  yellowish  or  brown  spots,  and  show  a 
tendency  to  break  down  and  bleed.  If  the  process  is  not  arrested 
during  this  stage  of  the  disease,  the  term  diphtheritic  infection  is 
used;  when,  however,  gangrene  and  ulceration  predominate,  the 
brown  spots  extend,  and  involve  the  entire  surface  of  the  wound,  soon 
converting  it  into  a  discolored,  fetid  mass,  the  borders  of  which  are 
sharply  defined ;  the  center  of  the  wound  becomes  gangrenous  and  the 
hemorrhagic  and  putrefactive  tissue  degeneration  extends,  gradually 
destroying  the  edges  of  the  crater-like  excavation.  The  infected  area 
is  surrounded  by  an  areola  of  red,  painful  inflammation,  reaching  far 
out  into  the  contiguous  tissues.  In  the  pulpous  form,  the  surface  of 
the  wound  is  dry  and  covered  with  a  thick,  dirty  gray,  fibrinous 


356  INFECTIONS  OF  WOUNDS 

exudate  wliich  becomes  necrosed  and  undergoes  gangrenous  separation, 
after  which,  the  wound  surfaces  swell,  become  gaseous,  and  are  con- 
verted into  a  gray  material  (pulpa)  that  has  somewhat  the  appearance 
of  brain  substance.  These  changes  are  frequently  accompanied  by 
parenchymatous  or  arterial  bleeding  (hemorrhagic  form).  The  focus 
extends  with  astonishing  rapidity,  covering  the  entire  surface  of  a 
stump,  following  amputation,  in  a  single  night. 

When  the  process  remains  superficial  (which  is  not  rare),  gan- 
grenous separation  of  the  necrosed  parts  is  followed  by  healing  by 
granulation. 

The  deep  form  takes  on  the  character  of  putrid  phlegmon  and  goes 
on  to  sequential  involvement  of  the  subcutis,  the  intermuscular  spaces, 
and  the  sheaths  of  the  blood  vessels.  Invasion  of  the  deep  fascia  is 
followed  by  disintegration  of  the  muscular  tissue  which  is  thrown  off 
in  the  form  of  large  sloughs.  The  periosteum  is  separated  from  the 
bone,  followed  by  necrosis  of  the  latter.  The  blood  vessels  degenerate, 
perforate,  and  menacing  bleeding  occurs. 

In  the  deep  form  the  rapid  absorption  of  toxic  elements  may  cause 
death  in  one  or  two  days.  Ivoenig,^^  who  had  ample  opportunity  to 
study  the  condition  in  connection  with  the  Franco-Prussian  War, 
states  that  the  mortality  depends  upon  the  hygiene  of  the  patient's 
surroundings,  and  upon  the  coexistence  of  other  diseases,  such  as 
cholera,  typhoid,  dysentery,  etc.,  and  varies  between  6  and  80.6 
per  cent. 

The  fever  of  hospital  gangrene  is  usually  of  the  continued  type, 
but  may  be  intermittent  in  character.  The  removal  of  the  local  focus 
or  the  application  of  acids  may  be  followed  by  a  sudden  drop  of 
temperature. 

The  systemic  symptoms  are  those  common  to  all  pyogenic  and  putre- 
factive processes. 

The  complications  are  those  likely  to  occur  where  there  is  infectious 
destruction  of  tissue — -erysipelas,  mixed  pyogenic  infections,  lymph- 
angitis, and  lymphadenitis. 

Identification  of  hospital  gangrene  is  not  an  easy  matter,  chiefly 
because  of  its  rarity  in  these  days  of  asepsis  and  surgical  cleanliness. 
The  superficial  form  resembles,  and  no  doubt  is  really,  a  form  of 
wound  diphtheria,  which  of  course  may  be  settled  readily  by  the  micro- 
scopical findings.  The  deep  form  would  not  seem  to  differ  particularly 
from  other  putrefactive  infections. 

The  treatment  consists  of  early  removal  of  the  offending  exudate, 


THE  PUTREFACTIVE  INFECTIONS  35? 

the  application  of  acids  (zinc  chlorid,  etc.),  and  the  liberal  use  of 
actual  cautery.  Deeply  located  pockets  are  made  accessible  by  means 
of  free  incision. 

Severe  bleeditig  is  controlled  by  ligature  of  the  afferent  arteries  in 
their  continuity,  i.  e.,  in  healthy  tissue. 

Amputation  may  be  resorted  to  as  an  extreme  measure  of  relief 
indicated  for  the  purpose  of  saving  life  when  general  infection  is 
menacing. 

BIBLIOGRAPHY 

1.  ScHOTMtJLLER.     Zentrbl.  f.  Bakt.,  1912. 

2.  Hauser.     Leipzig,  1885. 

3.  E.  Levy.     Arch.  f.  exper.  Path.  Bd.  34,  1894. 

4.  FoRNET  and  Hubner.    Arch.  f.  exper.  Path.  Bd.  65,  1911. 

5.  Seitz.     Zentrbl.  f.  Bakt.  Orig.  Bd.  67,  1913. 

6.  V.  Ermengen.     Kolle-Wassennann  Handb.  d.  Path.  Micro.  1  Aufl.  Ed. 

ii,  1903. 

7.  Wesenberg.     Zeitschr.  f.  Hyg.,  xxviii,  1898. 

8.  E.  Fraenkel.     Zeitsch.  f.  Hyg.  Bd.  40,  1902. 

9.  Welch  and  Nuttall.     In  Simmouds,  Monographs  of  Rockefeller  Inst. 

No.  5,  1915. 

10.  Hiss  and  Zinsser.     Text  Book  of  Bact.,  N.  Y.,  1916. 

11.  Pasteur.     Bull,  de  I'acad.  de  med.,  1877. 

12.  Koch.     Mitth.  a.  d.  kais.  Gesundheitsamt  i,  1881. 

13.  Gaffky.     Same  as  No.  12. 

14.  Jensen.     In  Kolle-Wassennann  Handb.  d.  path.  Mikroorg,  Aufl.  i,  Bd. 

ii,  1903. 

15.  Stolz.     Beitrz.  Klin.  Chir.  Bd.  33,  1902,  mit  lit. 

16.  KoPRAC.     Arch.  f.  klin.  Chir.  Bd.  72,  1904. 

17.  RoTHFUCHS.     Miinch.  med.  Woch.,  1906. 

18.  Lenhartz.     Wien,  1903. 

19.  Gohn  and  Sachs.     Zentrbl.  f.  Bakt.  1903,  Bd.  34  and  Bd.  36, 1904,  Orig. 

20.  Perthes.     Chir.  Kong.  Verbandl.,  1899,  ii. 

21.  Pawlowsky.     Arch.  f.  klin.  Chir.  Bd.  85,  1908. 

22.  Hartoch   and    Schurmaxn.     In   Kolle-Wassermann,   Handb.   d.   path. 

Mikroorg,  Aufl.  ii,  Bd.  8, 1913. 

23.  Matzenauer.     Arch.  f.  Dei-mat.  u.  Svphil.  Bd.  55,  1901. 

24.  Nasse.     Arch.  f.  klin.  Chir.  Bd.  43,  1892. 

25.  KoENiG.     Samml.  kHn.  Vortr.  No.  40,  1872. 

26.  Delpech.    Paris,  1815. 


CHAPTER  XIII 
POISONED    WOUNDS 

A  single  prick  of  an  insect  possessed  of  a  stinger  and  a  poison  sac 
(bees,  wasps,  hornets,  etc.),  or  the  bite  of  a  venomous  spider  may- 
produce  intoxication.  Infliction  of  the  sting  or  bite  is  followed  by 
local  inflammatory  swelling  and  the  constitutional  disturbances  com- 
mon to  poisoning,  i.  e.,  rapid  respiration,  acceleration  of  pulse,  syn- 
cope, collapse,  vomiting,  etc.,  especially  when  a  number  of  insects 
attack  simultaneously.  As  a  rule,  the  symptoms,  both  local  and  gen- 
eral, disappear  spontaneously,  but  a  single  wasp  or  bee  sting  has 
produced  a  fatal  outcome. 

When  the  bee  stings,  it  leaves  the  stinger  and  poison  sac  in  the 
wound;  these  should  be  removed  and  the  tiny  opening  dabbed  with 
dilute  ammonia  which  neutralizes  the  poison  (presumably  formic 
acid).  This  may  be  followed  by  the  application  of  sterile  menthol 
salve.  The  same  treatment  may  be  used  advantageously  in  connection 
with  the  bite  of  the  scorpion  and  wasp.  Fresh  mosquito  bites  are  best 
treated  with  the  application  of  naphthalin. 

Poisonous  snakes  are  widely  distributed  throughout  the  temperate 
and,  especially,  the  torrid  zones.  In  the  United  States,  about  seven- 
teen species  of  rattlesnakes  and  ten  species  of  copperheads  and  moc- 
casins, coral  and  harlequin  snakes,  etc.,  are  classed  as  poisonous,  as  is 
also  the  Texas  Gila  monster.  In  Europe  the  adder  and  the  viper  are 
dreaded,  while  in  India  much  attention  has  been  paid  to  the  Thanato- 
phidia.  Most  therapeutic  work  has  been  based  upon  the  venom 
furnished  by  the  cobra. 

The  poison  apparatus  of  snakes  consists  of  a  secreting  gland  on  each 
side,  which  communicates  with  a  tubular  fang  by  means  of  a  duct.  In 
the  passive  state,  the  fangs  are  directed  backward  on  the  roof  of  the 
mouth,  but  when  the  animal  strikes,  the  points  are  made  to  project 
forward  and  the  poison  is  forced  through  the  canals  by  muscular 
compression  of  the  sac.  The  venom  is  a  glandular  secretion 
(Pticketts^). 

358 


POISONED  AYOUNDS  359 

Bites  hi/  paisonous  snakfs  ma}'  be  recognised  by  the  two  small  punc- 
tured wounds  the  fangs  produce,  while  those  produced  by  the  harmless 
ones  are  zigzag. 

The  action  of  snake  venom,  like  that  of  many  bacterial  toxins, 
depends  upon  its  capacity  to  destroy  red  blood  corpuscles,  and  upon 
the  fact  that  it  contains  a  poisonous  protein  which  provokes  both  local 
and  constitutional  disturbances.  The  local  disturbances  begin  with 
severe  pain  and  swelling  in  the  region  of  the  wound ;  the  swelling  is 
at  first  not  colored  but  soon  exhibits  petechiae  and  extravasations  of 
blood,  while  the  enlargement  of  the  limb  rapidly  increases,  reaching, 
in  some  instances,  twice  its  normal  size  in  half  an  hour.  The  absorp- 
tion of  the  poison  provokes  lymphangitis  and  thromhophlehitiis; 
f-econdary  pyogenic  infection  causes  purulent  phlegmon,  and  necrosis 
and  gangrene  follow  obstruction  of  return  circulation  (by  constriction) 
or  the  entrance  of  putrefactive  bacteria.  A  few  hours  after  the 
injury,  the  general  disturbances  make  their  appearance ;  these  consist 
of  vertigo,  s^-ncope,  fever,  headache,  small  pulse,  d^-spnea,  feeling  of 
apprehension,  vomiting,  diarrhea  with  or  without  bloody  stools,  and 
collapse  —  s^-mptoms  which  lead  to  a  fatal  outcome  from  heart  failure 
in  from  three  to  nine  per  cent  of  the  cases ;  but  in  most  instances  they 
are  followed  by  recovery  in  a  few  days  (average  duration,  nine  days). 
General  weakness  may  persist  for  a  long  time.  Autopsy  usualh' 
reveals  extensive  clotting  of  blood  in  the  heart  and  blood  vessels,  or 
there  may  be  an  absence  of  coagulation  on  part  of  the  blood,  in  which 
event  the  organs  and  the  mucosa  of  the  gut  are  studded  with  small 
hemorrhages.  This  variation  depends  upon  whether  the  fibrin  formed 
by  ferments  is,  or  is  not,  dissolved  by  the  action  of  proteolytic  sub- 
stances (Calmette^). 

Poisoning  by  certain  classes  of  snakes,  such  as  the  rattler  and  the 
cobra,  is  attended  with  an  exceedingh'  grave  picture.  The  local  and 
general  symptoms  are  similar  to  those  described  above,  but  are  more 
severe  and  more  often  followed  by  death,  the  mortality  being  twenty 
per  cent.  In  East  India  20,000  persons  die  annually  of  snake  poison- 
ing. Injury  of  a  vein  is  promptly  fatal.  Ordinarily,  the  victim 
becomes  unconscious  and  delirious  in  a  few  minutes,  and  dies  in  a  few 
hours.  In  a  certain  number  of  cases,  the  affliction  takes  on  a  chronic 
form ;  a  peculiar  cachexia  attended  with  edema,  and  a  tendency  to  a 
hemorrhagic  diathesis  develops  and  results  fatally  after  the  lapse  of 
months  or  years.  It  is  interesting  to  note  that  snake  poison  present 
in  vitro  retains  its  virulence  indefinitely. 


360  INFECTIONS  OF  WOUNDS 

Calmette^  states  that  the  poisons  of  the  viper  and  the  cobra  classes 
vary  in  their  effects.  The  former  attacks,  almost  exclusively,  the 
blood  (increased  rapidity  of  coagulation),  while  the  latter  executes  its 
chief  effect  upon  the  central  nervous  system  (especially  the  vagus 
center).  The  bite  of  the  viper  class  provokes  more  local  disturbance 
than  that  of  the  cobra;  the  latter,  however,  is  followed  earlier  by 
severe  general  symptoms. 

The  treatment  of  snake  poisoning  is  directed  toward  removal  of  the 
poison,  the  prevention  of  its  absorption,  and  the  neutralization  of  its 
activities  in  the  body. 

Efforts  to  remove  the  poison  from  the  wound  and  to  obviate  its 
absorption  have  long  been  practiced  by  the  laity,  who  immediately 
suck  out  the  wound  and  apply  constriction  to  the  limb  above  it.  Suck- 
ing out  the  wound  with  the  lips  is  dangerous  only  when  these  are 
cracked  or  have  an  open  wound ;  indeed,  the  poison  may  be  swallowed 
without  evil  effects.  On  general  principles,  the  use  of  a  suction  glass 
is  advisable. 

The  most  effective  treatment  consists  of  immediate  excision  of  the 
■wounds  and  wide  incision  of  the  inflamed  parts,  together  with  central 
constriction,  with  the  view  of  promoting  the  discharge  of  serous  edema 
and  the  virus  it  may  contain.  The  constrictions  must  not  he  released 
until  the  incisions  are  made.  Neither  the  excision  of  the  "bite  area" 
nor  the  incisions  should  be  made  with  the  cautery,  as  its  use  does  not 
permit  of  the  free  discharge  of  the  poison.  The  incisions  and  the 
employment  of  constriction  hyperemia  (Freyer^)  are  more  effectual 
than  the  subcutaneous  injection  of  chemical  agents  (such  as  1-2  per 
cent  of  solution  of  potass,  permanganate,  etc.).  Cupping,  scarifica- 
tion, and  the  amputation  of  small  parts  are  useful  measures.  Aseptic 
care  of  the  wound  and  immobilization  of  the  part  are  necessary. 

The  constitutional  treatment  is  directed  toward  support  of  the  heart 
by  injections  of  camphor,  the  administration  of  alcohol,  and  by  saline 
hypodermoclysis  and  infusion. 

The  antitoxic  serum  treatment  is  based  on  the  work  of  Calmette,^"* 
who  immunized  the  blood  serum  of  horses  by  injecting  cobra  venom. 
He  also  used  the  venom  of  other  snakes  in  the  preparation  of  a 
polyvalent  serum.  For  extensive  discussion  in  this  connection  the 
reader  is  referred  to  special  literary  contributions  devoted  to  this 
subject.  In  addition  to  the  references  to  Freyer,^  Calmette,^"*  and 
Ricketts^  mentioned  above,  the  work  of  Krause^  may  be  advantageously 
perused. 


POISONED  WOUNDS  361 

Arrow  poison  wound  infection  takes  on  the  form  of  cardiac  failure 
and  tetany.  The  missile  is  coated  with  vegetable  poisons  such  as 
strychnia,  anti-arin,  strophanthus,  etc.,  or  with  animal  poisons  (snake 
venom  mixed  with  putrefactive  substances),  the  actions  of  which  are 
fatal  in  a  short  time.  Immediate  ''sucking  out"  of  the  wound  may 
save  life.  In  other  respects,  the  treatment  is  similar  to  that  of  snake 
and  insect  bites. 

Cadaveric  poisoning  of  the  purely  toxic  form  is  not  as  common  as 
bas  been  believed.  Although  the  cadaverin  of  Grawitz^  is  no  doubt 
responsible  for  a  systemic  poisoning  in  a  certain  number  of  cases,  the 
dangerous  and  fatal  ones  arise  from  the  invasion  of  highly  virulent 
pyogenic  bacteria  derived  from  the  fresh  cadaver,  especially  when 
death  is  due  to  peritonitis,  meningitis,  general  pyogenic  infection,  etc. 
Injuries  received  while  dissecting  old  cadavers  are  rarely  followed  by 
more  than  local  reaction,  and  these  soon  clear  up  if  protected  from 
secondary  infection.  The  application  of  concentrated  acetic  acid  to 
wounds  of  this  class  is  a  time  honored  and  effective  mode  of  treatment. 


BIBLIOGRAPHY 

1.  RiCKETTS.     Inf.  Immun.,  etc.,  Chicago,  111.,  1911. 

2.  Calmette.     Handb.  d.  Immun.  of  Kraus  and  Levaditi,  Bd.  i,  1907. 

3.  Freyer.     Arch.  f.  Schiff  u.  Tropenhys".  Bd.  14,  1910. 

4.  Calmette.     In  Kolle-Wassermann  Handb,  d.  path.  Microorg.  Aufl.  ii, 

Bd.  2,  1913. 

5.  Krause.     Arch.  f.  Schiff  u.  Tropenhyg.,  1908. 

6.  Grawitz.     Virchow's  Arch.  Bd.  110, 1887. 


CHAPTER  XIV 
EABIES,   LYSSA,    HYDROPHOBIA 

Rabies,  in  man,  is  an  acute,  fatal,  infectious  disease  most  frequently 
caused  by  the  bite  (90  i^er  cent)  or  by  the  saliva  of  an  infected  dog. 

The  exact  character  of  the  rabies  virus  is  not  known.  The  round 
or  oval  bodies  (4-10  microns),  described  by  Negri^  (1893)  and  veri- 
fied by  Bertarelli^  and  others,  found  in  the  cells  of  the  large  ganglia, 
spinal  cord,  etc.,  are  not  found  in  the  saliva,  and  although  character- 
istic of  the  disease,  may  not,  at  this  time,  be  accepted  as  the  causative 
protozoa.  Their  presence  ma}',  however,  be  considered  of  determining 
diagnostic  significance. 

Animal  experimentation  shows  that  the  virus  provocative  of  the 
disease  is  contained  in  the  central  nervous  system,  in  the  peripheral 
nerves,  and  in  the  saliva.  In  the  last,  it  has  been  found  during  the 
period  of  incubation.  The  virus  seems  to  extend  along  the  nerve 
trunks  to  the  centers  (Babes,^  Wyssokowicz,^  etc.).  This  has  been 
proved  in  the  experimental  production  of  the  disease.  Rabies  is  pro- 
voked with  greatest  certainty  by  the  subdural  injection  of  emulsions 
of  brain  and  spinal  cord  material  taken  from  the  cadavers  of  persons 
or  animals  who  died  of  that  disease. 

All  mammalia  are  susceptible  to  rabies.  It  is  conveyed  by  dogs, 
eats,  wolves,  and  foxes.  One  case  in  which  the  infection  was  derived 
from  the  human  is  reported  by  Marx^. 

In  dogs,  after  a  period  of  incubation  of  from  three  to  five  weeks, 
the  disease  shows  its  prodromal  stage  consisting  of  restlessness,  loss  of 
appetite,  attempts  at  vomiting,  and  irritability  which,  after  a  few 
days  goes  on  to  the  stage  of  irritation  (the  real  disease).  Before  the 

DE\TSLOPMENT    OF    DEFINITE   SYMPTOMS,    THE   SALIVA   ALREADY    CONTAINS 
THE  VIRUS,  AND  A  BITE  DURING  THIS  TIME  WILL  CONVEY  THE  DISEASE. 

The  clearly  defined  disease  in  dogs  is  divided  into  two  forms,  the 
raging,  and  the  paralytic;  the  former  dcnoiing  that  the  chief  lesion 
is  in  the  brain,  and  the  latter,  that  the  cord  is  mainly  involved.  The 
convulsive  or  maniacal  form  begins  with  a  stage  of  irritation  in  which 

362 


RABIES  363 

the  animal  exhibits  great  irritability  and  a  tendenc}'  to  bite,  wanders 
aimlessly  about,  howls,  barks,  and  rapidly  emaciates  as  the  result  of 
the  ingestion  of  dirt,  wood,  feces,  etc.,  instead  of  the  usual  articles  of 
diet.  Pharyngeal  spasm  occurs  when  efforts  to  drink  are  made,  con- 
veying the  idea  of  fear  of  water,  a  symptom  from  which  the  disease 
derives  its  name  of  hydrophohia.  On  the  third  or  fourth  day  the 
stage  of  parahjsis  appears,  which  consists  of  progressive  paralysis, 
beginning  in  the  hind  legs  and  gradually  extending  until  death  (three 
to  six  days  later)  occurs.  The,  so-called,  paralytic  form  ends  more 
rapidly  as  the  stage  of  irritation  is  omitted.     It  is  comparatively  rare. 

In  man,  the  disease  is  characterized  by  a  very  long  perioel  of  incu- 
bation, usually  twenty  to  sixty  days,  though  it  varies  from  two  weeks 
to  six  months.  Longer  periods  are  doubtful.  Not  all  persons  bitten 
by  rabid  animals  develop  rabies,  as  the  clothing  may  prevent  the 
entrance  of  saliva  into  the  wound.  The  proportion  of  bitten  persons 
who  develop  the  disease  is  probably  less  than  one-third,  and  these  are 
usually  injured  in  exposed  portions  of  the  body,  i.  e.,  the  head,  face, 
and  hands  (Babes'). 

The  proelromal  stage  oegins  with  pain  in  the  region  of  the  "bite 
wound"  or  scar,  and  extends  in  the  course  of  the  nerve  trunks;  a 
slight  redness  appears  in  the  vicinity  of  the  wound,  or  the  granulations 
take  on  an  unhealthy  appearance.  Gradually  the  symptoms  of  a 
severe  general  illness  develop  —  loss  of  appetite,  headache,  melan- 
choly, restlessness,  apprehension,  insomnia,  slight  difficulty  in  degluti- 
tion, respiratory  embarrassment,  repugnance  to  drinking,  and  a  slight 
rise  of  temperature.  In  a  few  hours  or  days,  deglutition  of  fluids 
hecomes  peiinful,  so  that  the  afiflicted  person  fears  the  act  of  drinking 
(hydrophobia),  and  may  have  spasm  of  the  pharyngeal  muscles  pre- 
cipitated by  the  sight  of  water,  or  even  by  attempts  to  swallow  the 
Falivary  secretion;  during  this  period  reflex  irritabilit}'  is  greatly 
increased.  The  skin  is  especiall}-  sensitive;  gentle  stroking,  blowing 
of  the  breath  on  the  surface  of  the  body,  the  slamming  of  a  door, 
heavy  footfalls,  the  rustle  of  leaves,  etc.,  will  provoke  dyspnea  or  clonic 
spasm  of  the  entire  musculature.  The  pupil  usually  is  dilated  by 
surface  irritation,  and  especially  by  extrinsic  noises  (Schaffer^). 
When  the  increased  irritability  of  the  reflex  centers  in  the  cord 
extends  to  the  medulla,  the  reflex  action  is  gradually  abolished  (the 
dilated  pupils  no  longer  respond  to  light,  bladder  control  is  lost,  etc.) 
and  delirium  takes  the  place  of  irritability.  Soon  paralysis  of  exten- 
sive portions  of  the  body  occurs  (lumbar  and  cervical  paraplegia)  and 


364  INFECTIONS  OF  WOUNDS 

in  a  few  hours  more,  the  last  convulsive  period  develops,  during  which 
the  patient  vomits  persistently,  and  is  again  attacked  by  violent  gen- 
eral convulsions.  Exhaustion  and  cardiac  insufficiency  soon  result  in 
death  (three  to  six  days),  which  is  usually  preceded  by  a  very  high 
temperature.  Unfortunately,  consciousness,  as  a  rule,  persists  until 
the  end. 

The  pathology  of  rabies  is  that  of  an  inflammatory  degeneration  of 
the  central  nervous  system,  especially  the  cord  (acute  myelitis).  The 
process  is  most  active  in  that  portion  of  the  cord  from  which  the 
nerves  supplying  the  wound  area  are  derived  (Schaffer^). 

Rabies  may  be  confused  with  cephalic  tetany  and  hysteria. 

The  treatment  of  a  person  bitten  by  a  rabid  animal  or  by  one  sus- 
pected of  having  the  disease  is  directed  toward  making  the  virus  harm- 
less before  it  has  an  opportunity  to  develop  pathogenesis.  The  near- 
est approach  to  this  is  accomplished  by  thorough  excision  of  the  wound, 
amputation  of  small  parts,  and  the  open  treatment  of  wminds. 
Cauterization  of  the  wound  is  unsatisfactory,  as  the  scab  which  forms 
after  it  interferes  with  the  egress  of  the  virus.  "When  the  tissues  are 
deeply  lacerated,  the  edges  of  the  wound  must  be  thoroughly  trimmed 
and  the  pockets  drained  by  means  of  light  tamponade. 

The  long  period  of  incubation  in  man  makes  the  local  treatment  of 
greater  value  than  obtains  in  connection  with  animals.  Babes^  claims 
that  if  the  ''bite  wound"  is  thoroughly  cauterized  with  the  actual 
cautery  within  five  minutes  after  its  infliction,  hj^drophobia  will  be 
avoided. 

After  the  disease  is  developed,  efforts  to  control  the  symptoms  by 
means  of  opiates  and  narcotics  should  be  made.  Penzoldf^  injects  0.2 
to  0.3  gm.  doses  of  curare  every  hour.  The  introduction  into  the 
rectum  of  the  ether-oil  mixture  described  in  connection  with  rectal 
narcosis  (p.  137)  would  seem  to  be  justified.  Meltzer  and  Auer's* 
intraspinal  injection  of  magnesium  sulphate,  which  parah'zes  spinal, 
sensory,  and  motor  conduction,  employed  by  Haubold^  for  operative 
procedures  below  the  diaphragm,  and  by  Blake^°  and  others  in  connec- 
tion with  the  treatment  of  tetanus,  would  also  seem  worthy  of 
consideration. 

Despite  police  regulations  with  respect  to  domestic  animals,  rabies 
still  occasional!}^  occurs.  This  would  make  imperative  the  employment 
of  measures  of  prophylaxis  in  all  cases  of  wounds  inflicted  by  dogs, 
cats,  wolves,  etc.,  measures  which  at  this  time  are  limited  to  the 
Pasteur  protective  vaccination  treatment. 


RABIES  365 

The  Pasteur  method  consists  of  taking  advantage  of  the  long  period 
of  incubation  of  the  disease  in  man  to  create  in  the  patiext  in  a 

SHORT  PERIOD  OF  TIME AND  BEFORE  THE  BEGINNING  OF  THE  SYSTEMIC 

SYMPTOMS  —  A  TOLERANCE  FOR  A  LARGE  QUANTITY  OF  THE  VIRUS,  AND 
THUS    PREVENT    THE    DEVELOPMENT    OF    THE    DISEASE.      After    years    of 

patient  reinoculation,  Pasteur  was  able  to  obtain  a  highly  virulent 
virus  {Virus  fijce)  in  rabbits,  so  that  the  period  of  incubation  and  the 
duration  of  the  disease  were  markedly  reduced.  The  spinal  cord  of 
rabbits  may  be  rendered  less  virulent  by  drying  in  a  suitable  appa- 
ratus, finally  becoming  avirulent  for  these  animals  after  being  dried 
for  fourteen  days. 

Virus  fixe  is  of  a  strength  which,  when  injected  subdurally  into  the 
rabbit,  is  followed  by  the  development  of  rabies  in  from  six  to  seven 
days.  The  term  "street  virus"  is  applied  to  the  one  ordinarily 
obtained  from  infected  animals. 

Although  virus  fixe  represents  its  highest  degree  of  virulence  for 
rabbits,  there  is  no  good  reason  for  believing  that  repeated  passage 
through  the  rabbit  decreases  the  virulence  of  the  virus  for  man 
(Ricketts'^). 

The  result  of  the  experimental  labors  of  Pasteur  has  been  applied  to 
man,  and  would  seem,  according  to  present  observation,  to  be  the  one 
effectual  means  we  have  to  prevent  the  development  of  the  disease 
Marx,^  Pozevski^-).  In  cases  in  which  the  period  of  incubation  is 
short  (about  two  weeks),  as  often  happens  when  the  injury  involves 
the  face,  or  when  cases  are  not  treated  early  enough,  the  treatment  is 
likely  to  fail.  However,  rapid  increase  in  the  dosage  of  the  injections 
reaches  its  maximum  in  three  days  and  may  be  successful  even  in 
these  cases.  It  is  evident  that  the  treatment  is  best  begun  soon  after 
the  infection  is  introduced.  Protective  substances  are  contained  in 
the  blood  of  persons  treated  with  immunizing  injections  (Kraus  and 
KreiseP*). 

The  technic  of  preparing  the  virus  is  a  complicated  one,  and  requires 
special  apparatus  and  especial  skill.  Its  effectiveness  is  dependent 
upon  the  establishment  of  laboratories  by  the  government  to  which 
patients  maj'  be  sent.  The  mortality  of  this  truly  horrible  affliction 
in  cases  subjected  to  the  Pasteur  treatment  is  stated  by  Marx^  to  be 
only  0.3  to  0.5  per  cent.  Babes^  states  that  the  treatment  has  reduced 
the  mortality  following  wolf  bites  from  90  per  cent  to  10-15  per  cent. 

The  injection  of  the  blood  serum  of  immunized  dogs  has  also  given 
favorable  results  (Babes^  and  others). 


366  INFECTIONS  OF  WOUNDS 

BIBLIOGRAPHY 

1.  Negri.     Zeitsclir.  f.  Hyg.  u.  Infkrank.,  Bd.  63,  1909. 

2.  Bertarelli.     Zentrbl.  f.  Bakt.  Bd.  37,  1906,  with  lit. 

3.  Babes.     In  Penzoldt  and  Stinzings  Hand)),  d.  spec.  Therap.  Bd.  i,  1909, 

with  lit. 

4.  Wyssokowicz.     Zentrbl.  f.  Bakt.,  1891,  Bd.  10. 

5.  Marx.     Klin.  Jahrb.  Bd.  7,  1900. 

6.  ScHAFFER.     Beitr.  z.  path.  Anat.  Bd.  7,  1890,  with  lit. 

7.  Pekzoldt.     Same  as  No.  3. 

8.  Meltzer  and  Ai'er.     Studies  from  the  Rockefeller  Inst.,  1906,  v. 

9.  Haubold.     See  Meltzer,  Jr.  Exp.  Med.,  1906. 

10.  Blake.     Same  as  No.  8. 

11.  RiCKETTS.     Inf.  and  Immun.,  etc.,  Chicago,  111.,  1911. 

12.  PozEVSKi.     Weiehardt's  Jahrb.  der  Immun.  Bd.  7,  1912. 

13.  Kraus  and  Kreisel.     Zentrbl.  f .  Bakt.  Bd.  32,  1902. 


CHAPTER  XV 
TETANUS 

In  1884  Carlo  and  Rattone^  succeeded  in  producinj^  tetanus  in 
rabbits  by  the  inoculation  of  pus  from  the  cutaneous  lesion  of  a  human 
case,  and  in  the  same  year,  Nicolair-  produced  the  disease  in  mice  by 
inoculation  with  garden  soil,  in  which  a  bacillus  with  a  round  end  had 
been  found  by  microscopical  examination.  In  1885,  Rosenbach^  dis- 
covered a  similar  bacillus  in  the  wound  of  a  case  of  tetanus.  It 
remained,  however,  for  Kitasato*  (1889)  to  definitely  establish  the 
bacterial  etiology  of  the  disease,  by  obtaining  from  a  case  of  tetanus, 
pure  cultures  of  the  bacilli,  with  which  he  provoked  the  disease  in 
animals.  Kitasato  succeeded  where  others  failed  because  of  his  use 
of  anaerobic  methods,  and  by  eliminating  contamination  with  non- 
spore  bearing  bacteria,  by  means  of  heat. 

The  bacillus  tetanus  (Fig.  1-13)  is  a  slender  rod,  two  to  five  microns 
in  length  and  0.3  to  0.8  microns  in  breadth.  The  vegetative  forms, 
which  occur  chiefly  in  young  cultures,  are  slightly  motile  and,  accord- 
ing to  Yotaller^',  are  seen  to  possess  numerous  peritrichal  flagella  when 
stained  by  special  methods.  After  twenty-four  to  forty-eight  hours 
of  incubation,  the  length  of  time  depending  somewhat  upon  the  nature 
of  the  medium  and  the  degree  of  anaerobiosis,  the  bacilli  develop  spores 
which  are  characteristically  located  at  one  end,  giving  the  bacterium 
its  diagnostic  drumstick  appearance. 

As  the  culture  grows  older  the  spore  bearnig  forms  completely 
supersede  the  vegetative  ones,  and,  ultimately,  the  cultures  contain 
spore  bearing  bacilli  and  spores  only. 

In  nature,  the  tetanus  bacillus  is  found  to  occur  in  the  superficial 
layers  of  the  soil.  The  earth  of  cultivated  and  manured  fields  seems 
to  harbor  the  organism  with  especial  frequency,  probably  because  of 
its  presence  in  the  dejecta  of  some  of  the  domestic  animals. 

Biologically,  the  bacillus  is  generally  regarded  as  an  obligatory 
anaerobe.  While  it  is  true  that  growth  is  ordinarily  obtained  only  in 
the  complete  absence  of  oxygen,  several  observers  (Ferran,®  Belfanti/ 


368 


INFECTIONS  OF  WOUNDS 


and  others)  have  successfully  habituated  the  bacillus  to  aerobic  con- 
ditions by  the  gradual  increase  of  oxygen  in  cultures.  Habituation 
to  aerobic  conditions  is,  however,  attended  with  lessening  or  loss  of 
pathogenicity  and  toxin  formation.  Anaerobic  conditions  may  also 
be  dispensed  with  when  tetanus  bacilli  grow  in  consort  with  some  of 
the  aerobic  bacteria.  The  addition  to  culture  media  of  suitable  carbo- 
hydrates, and  of  fresh  sterile  liver  tissue,  has  also  been  found  to  render 
it  less  exacting  as  to  absolute  anaerobiosis  (Smith,  Brown,  and 
Walker«). 


^^HH 

WBKKSM'           *^  ■■■■'■^\-  >--^-  -            ':M^ 

^^^H^P 

^'^'  .  '■-  ^'-^?f,"m 

^^H":^' 

f       ■    v....  :■  -  .-W.  ' 

*    • 

-■ :  ^•;     • 

S^^  '  ■"^'^A  -\^-  --m 

Fig.  143. —  Tetanus  Bacilli. 


Anaerohic  growth  of  the  bacillus  tetani  takes  place  upon  meat 
infusion  broth  which  it  clouds  within  twenty-four  to  thirty-six  hours. 
Anaerobic  broth  cultures  may  be  prepared  by  covering  the  surface  of 
the  medium  with  a  layer  of  albolin  or  other  heavy  oil  and  driving  off 
the  air  by  heat. 

On  agar  and  gelatin,  at  a  temperature  of  37.5°C.  (99.4°F.),  growth 
appears  within  forty-eight  hours.  On  agar  plates,  the  colonial  flora 
presents  a  characteristic  appearance,  consisting  of  a  compact  center 
surrounded  by  a  meshwork  of  fine  filaments,  not  unlike  the  "Medusa 


TETANUS  369 

head"  arrangement  of  the  subtilis  colonies.  In  gelathi  stabs,  gas  is 
formed,  and  the  medium  liquefies.  Old  cultures  emit  an  offensive  odor. 

For  experimental  purposes,  guinea  pigs,  mice,  and  rabbits  are 
largely  used.  Inoculation  with  virulent  cultures  is  promptly  followed 
by  fatal  tetanus.  When  the  culture  medium  is  subjected  for  five 
minutes  to  a  temperature  of  65°C.  (149°F.),  it  becomes  ineffective,  as 
heat  destroys  the  toxins  of  the  tetanus  bacillus;  pathogenesis  may, 
however,  be  provoked  by  the  inoculation  of  large  quantities  of  heated 
medium  which  still  contains  viable  spores.  The  bacilli  must  he  inocu- 
lated together  with  their  products.  When  this  is  done,  and  by  using 
especially  toxic,  old  cultures,  or  a  foreign  substance  which  has  already 
been  responsible  for  the  infection  in  a  human,  fatal  tetanus  is  devel- 
oped in  the  recipient,  after  a  period  of  incubation  of  from  one  to  three 
days.  In  these  instances,  the  bacterial  excitants  are  not  restricted  to 
the  region  of  the  wound,  but  are  found  disseminated  throughout  the 
organs,  the  blood,  the  cord,  and  the  spinal  fluid  (Reinhardt  and 
Assim® ) . 

When  bouillon  cultures  are  passed  through  the  Berkef  eld  filter,  the 
filtrate,  though  free  from  bacteria,  possesses  a  degree  of  virulence  equal 
to  that  of  the  provocative  excitants,  showing  that  the  tetanus  toxin  is 
formed  in  the  culture  fluid.  As  a  matter  of  fact^  the  comparative 
infrequency  of  tetanus  infection  is  in  marked  contrast  to  the  wide 
distribution  of  the  bacilli  in  nature.  Introduced  into  the  animal  body 
as  spores,  and  free  from  toxins,  they  often  fail  to  incite  disease,  easily 
falling  prey  to  phagocytes  and  other  protective  agencies  before  the 
vegetative  forms  develop  and  toxin  is  created.  This  was  demonstrated 
by  Vaillard  and  Rouget^°  who  introduced  tetanus  spores  inclosed  in 
paper  sacs  into  the  body  of  animals.  By  the  paper  capsules,  the 
spores  were  prevented  from  coming  in  contact  with  the  leukocytes, 
but  were  still  subjected  to  the  action  of  the  body  fluids ;  nevertheless, 
tetanus  developed. 

The  filtrate  of  bouillon  culture  is  soluble  in  water,  and  may  be 
precipitated  by  the  addition  of  natrium  ammonium  sulphate,  or  zinc 
chlorid  (Brieger  and  Cohn").  After  the  precipitate  is  dried,  it  may 
be  used  for  experimental  purposes. 

The  pathogenicity  of  tetanus  toxin  is  dependent  upon  the  virulence 
of  the  bacteria,  and  is  increased  by  symbiosis  with  other  bacteria. 
Debrand^^  obtained  high  virulence  by  sjTnbiosis  with  the  bacillus 
subtilis. 

For  the  purpose  of  identifying  tetanus  bacilli  in  the  wound,  foreigli' 


370  INFECTIONS  OF  WOUNDS 

bodies  or  particles  of  earth  are  removed  from  it,  and  inoculated  into  a 
susceptible  animal  j  after  its  death,  the  bacilli  may  be  found  in  the 
secretions  of  the  wound  at  the  point  of  inoculation  and  cultured. 

The  port  of  entrance  of  tetanus  infection  is  always  a  wound.  Al- 
though a  clinical  classification  into  traumatic  and  rheumatic  tetanus 
has  been  made,  it  is  fair  to  assume  that  in  the  latter  instance  the  port 
of  entrance  has  escaped  detection,  for  a  minute  solution  of  continuity 
of  the  surface  is  sufficient  to  permit  the  infection  to  enter  the  body  and 
provoke  the  disease.  Frequently,  the  causative  bacteria  gain  access 
through  extensive  wounds  in  which  earth  and  other  foreign  material  is 
embedded,  such  as  occur  in  compound  complicated  fractures;  lacera- 
tions due  to  grenade  fragments,  or  splinters  of  wood,  and  hums 
(seldom)  ;  they  also  gain  access  through  traumatized  acne  pustules, 
insect  hites,  the  navel  of  the  newborn  {tetanus  neonatorum) ,  the  post 
partum  uterus  (tetanus  puerperalis) ,  and  injuries  to  the  epithelium  of 
the  mucosa  of  the  nose  and  mouth  (probably  the  tetanus  rheumalicus) . 

The  rarity  of  tetanus,  considering  the  wide  distribution  of  the 
bacilli  and  the  viability  evinced  by  the  spores,  is  shown  by  an  instance 
in  which  a  splinter  of  wood  which  had  given  rise  to  tetanus  was  still 
capable  of  provoking  the  disease  when  implanted  in  an  animal  at  the 
end  of  eleven  years.  It  would  seem  that  the  presence  in  (he  wound 
of  the  bacilli  alone  is  not  sufficient  to  provoke  tetanus,  but  that  cer- 
tain other  conditions  are  necessary;  of  these,  the  coincident  presence 
of  cooperative  saprophitic  bacteria,  as  already  stated,  is  the  most 
important  (v.  Lingelsheim^^).  In  addition  to  this,  severe  trauma  and 
its  consequent  necrosis,  and  the  presence  of  foreign  bodies,  favor 
putrefactive  infection,  all  of  which  create  soil  favorable  to  tetanus  in- 
vasion. When  the  influence  of  thorough  cleansing  and  adequate 
drainage  of  wounds  is  considered,  in  obviating  the  conditions  favorable 
to  infection,  it  is  easy  to  see  why  the  occurrence  of  tetanus  is  generally 
prevented  when  wounds  are  properly  cared  for. 

Epidemic  tetanus,  as  it  occurs  at  times  in  soldiers  during  war,  is 
explainable  on  the  ground  stated  in  connection  with  dirt,  foreign 
bodies,  etc.,  in  wounds,  and  especially  because  of  the  absence  of  prompt 
and  efficient  care. 

Postoperative  tetanus  is  due  to  contamination  of  the  wound  by 
hands,  instruments,  ligature  and  suture  material — especially  catgut. 
It  rarely  occurs  in  these  days  of  asepsis  (Braunn")  ;  occasionally 
perhaps  after  gynecological  operation  (Koch,^^  Philips,"  Kuhn  and 
Rossler^^). 


TETANUS  371 

Dissemination  of  the  hacilli  in  the  tissues  does  not  often  extend 
beyond  the  port  of  entrance  and  its  immediate  environment,  although, 
the  excitants  have  been  found  in  the  neighboring  lymph  nodes,  the 
vital  organs,  and  the  blood ;  they  have  also  been  found  in  the  cadaver 
(Reinhardt  and  Assim^°). 

The  period  of  incubation  in  the  human  varies  between  twenty-four 
hours  and  sixty  days,  though  from  eight  to  fourteen  days  is  the  usual 
period.  Laboratory  inoculation  with  a  sterile  culture  has  been  fol- 
lowed by  tetanus  in  four  days.  It  is  believed  that  the  bacilli  invade 
the  w^ound,  multiply,  and  cause  the  development  of  toxins  which  are 
absorbed  and  ultimately  affect  the  central  nervous  sj^stem. 

The  appearance  of  the  wound  is  in  no  way  indicative  of  tetanus 
infection.  The  local  process  may  be  purulent,  or  putrid  ;  granulations 
may  have  appeared,  or  cicatrization  may  have  been  completed  when 
the  disease  develops.  Foreign  bodies,  which  so  frequently  harbor  the 
provocative  excitants,  are  often  present,  even  in  healed  wounds. 

The  cli7iical  picture  of  tetanus  is  dominated  by  tonic  muscular 
rigidity  with  irregular  clonic  exacerhations,  beginning  most  frequently 
in  the  muscles  of  mastication  (so-called  trismus),  occasionally  in  the 
muscles  about  the  port  of  entrance  of  the  infection  {local  contrac- 
tures), and  gradually  extending  over  the  greater  portion  of  the  body. 
The  temperature  varies ;  in  some  instances  it  is  high  at  the  onset ;  in 
others,  it  begins  low  and  reaches  a  considerable  height  near  the  end ; 
or  fever  may  be  absent. 

The  disease  runs  an  acute  or  a  chronic  course. 

In  the  acute  form,  the  locked  jaw  is  rapidly  followed  by  tonic  con- 
traction of  the  muscles  of  the  neck  and  face;  the  muscles  of  the  hack, 
abdomen,  and  extremities  soon  exhibit  clonic  spasm.  The  arms  are 
usually  less  markedly  contracted.  The  rigidity  of  the  face  muscles 
gives  to  the  mouth  a  characteristic  grinning  expression  (risus  sardoni- 
cus)  and  causes  a  peculiar  w^rinkling  of  the  forehead  and  cheeks 
(fades  tetanicus). 

The  tonic  contractions  involving  the  entire  bod}^  are  more  or  less 
frequently  interrupted  by  periods  of  relaxation,  but  are  reasserted 
upon  the  slightest  external  irritation,  such  as  sudden  noises,  contact 
with  the  hands  of  the  attendant,  etc.  This  increased  reflex  irritability 
gradually  progresses  until  the  periods  of  rest  are  more  and  more 
widely  separated. 

During  the  quiescent  periods  the  patient  is  bathed  in  sweat,  the 
clenched  teeth  are  exposed  by  the  distorting  contracted  muscles;  the 


372  INFECTIONS  OF  WOUNDS 

eyes  stare  apprehensiveh^  into  space,  awaiting  with  terror  the  onset 
of  another  muscular  spasm  which  usually  causes  the  body  to  assume 
the  position  of  opisthotonos.  Spasm  of  the  sphincters  prevents  the 
discharge  of  urine  and  feces;  contracture  of  the  respiratory  muscles 
(at  the  end  of  twenty- four  hours)  gives  rise  to  attacks  of  suffocation 
which,  together  with  spasm  of  the  glottis,  cardiac  failure,  and  aspira- 
tion pneumonitis,  may  result  in  death.  Just  before  death,  the  temper- 
ature rises  to  43°-44°C.  (109°-111°F.),  a  phenomenon  ascribed  to  the 
increase  of  muscle  work. 

"While  the  severe  cases  terminate  fatally  in  from  four  to  five  days, 
each  day  that  the  patient  survives  thereafter  is  a  distinct  gain,  for,  at 
the  end  of  a  week,  rigidity  becomes  less  marked,  the  attacks  of  spas- 
modic contracture  less  frequent  and  various  groups  of  muscles  relax 
and  are  not  concerned  in  the  successive  spasms.  If  there  be  no  recur- 
rence, and  no  complications  develop  (such  as  pneumonitis)  the  patient 
gradually  recovers.  A  more  favorable  outlook  is  indicated  by  lessen- 
ing of  the  tension  in  the  face  muscles,  and  of  the  sweating,  though 
these  need  not  be  regarded  as  of  unfailing  prognostic  significance. 

When  the  disease  is  primarily  chronic,  the  severit}^  of  symptoms 
attendant  upon  the  acute  form  is  never  reached.  The  respiratory 
muscles  are  not  involved;  fever,  if  any,  is  moderate  in  degree,  and  the 
disturbances  are  restricted  to  difficulty  in  degultition,  locked  jaw,  and 
rigidity  of  the  neck.  Eecovery  takes  place  in  from  one  week  to  three 
months. 

The  prognosis  is  indicated  b}^  the  promptness  with  which  muscular 
spasm  appears;  that  is,  the  earlier  this  is  manifested  the  more  un- 
favorable is  the  outlook.  The  mortality  of  the  disease  is  variously  esti- 
mated to  be  between  80-90  per  cent.  Rose^^  gives  the  mortality  as  91 
per  cent  in  the  first  week  and  50-53  per  cent  in  the  second  week. 

Recognition  of  tetanus  is  not  fraught  with  confusing  elements.  The 
chronic  form,  beginning  with  a  locked  jaw  and  a  .slight  rise  of  tempera- 
ture, must  be  differentiated  from  local  processes  of  a  different  nature, 
also  responsible  for  these  manifestations.  The  rigidity  of  the  masseter 
muscles  in  tetanus  is  helpful  in  this  connection 

Tetanus  neonatorum  develops  on  the  first  lO  the  fifth  day  after 
separation  of  the  umbilical  cord.  Positive  bacterioscopic  findings  in 
the  exudate  of  the  narel  wound  make  the  diagnosis  certain.  Beyond 
the  usual  symptoms,  suspicion  should  be  aroused  by  the  tendenej^  the 
infant  shows  to  relinquish  suddenly  the  spasmodically  engulfed  nipple 
of  the  mother.    This  act  is  usually  accompanied  by  a  loud,  piercing  cry. 


TETANUS  373 

Tetanus  puerperalis  results  from  unclean  management  of  the  de- 
livery, and  not  infrequently  follows  efforts  at  provoking  aboi-tions. 
The  infection  enters  through  the  uterine  mucosa,  in  which  situation 
the  presence  of  the  bacillus  tetani  has  been  demonstrated.  The  disease, 
contracted  in  this  way,  follows  a  stormy  course,  and  is  invariably  fatal. 

Tetanus  cephalis  follows  infection  in  the  area  supplied  by  the 
twelfth  cranial  nerve,  and  has  been  variously  characterized  in  accord 
with  the  chief  symptoms  accompanying  it.  In  the  acute  severe  form, 
the  domination  of  spasm  of  the  muscles  of  deglutition  and  of  the  glottis 
has  led  Rose^®  to  employ  the  term  tetanus  hydrophobia;  when  tetanic 
jactitation  of  the  tonically  contracted  muscles  of  mastication  and  of 
the  face,  together  with  paralysis  of  the  cranial  nerves  (especially  the 
se.venth)  predominate,  he  uses  the  term  tetanus  facialis,  and  Klemm^'' 
the  term  tetanus  paralyticus.  To  these  are  added  rigidity  of  the  neck, 
torso,  and  extremities.  Death  results  from  suffocation  during  a 
spasm  or  from  heart  failure. 

In  the  subacute  and  chronic  forms,  the  s^Tnptoms  may  be  moderate 
in  degree,  and  are  frequently  restricted  to  the  zone  of  distribution  of 
the  cranial  nerves.  According  to  Brunner^°,  these  cases  begin  with 
tonic  contraction  of  the  muscles  supplied  by  the  seventh  nerve  on  the 
injured  side,  or,  if  the  injury  be  in  the  center  of  the  face,  the  distribu- 
tion of  both  nerves  is  affected ;  this  is  followed  by  spasm  of  the  muscles 
of  mastication — usually  on  the  injured  side ;  in  other  instances, 
paralysis  in  the  zone  dominated  by  the  facial  nerve  or  nerves  is  added 
to  the  spasm.  Strange  to  say  the  distribution  of  the  motor  roots  of 
the  fifth  nerATs  are  not  involved.  Wounds  of  the  eye  have  been  fol- 
lowed by  paralysis  of  the  oculomotor  and  trochlear  distributions.  It 
is  probable  that  in  these  instances  the  toxin  spreads  along  the  course 
of  these  nerves,  damaging  their  nuclei,  thus  causing  the  paralysis. 
These  forms  of  tetanus  are  rarely  attended  with  fever. 

The  treatment  of  tetanus  with  antitoxin  serum  is  based  on  experi- 
mental findings.  Its  action  can  be  understood  only  from  the  viewpoint 
of  the  behavior  of  the  tetanus  toxin  in  the  animal  body. 

It  is  certain  that  the  dissemination  of  tetanus  poison  from  the  port 
of  entrance  takes  place  through  the  blood  current  and  by  way  of  the 
peripheral  nerve  trunks.  The  presence  of  the  toxin  in  the  blood,  how- 
ever, can  be  demonstrated  only  when  muscular  spasm  develops 
(Blumenthal-^),  and  must,  therefore  be  stored  up  somewhere  in  the 
body,  probably  in  the  neuromuscular  apparatus,  from  which  it  is  liber- 
ated by  the  violent  muscular  contraction.    Experimentally,  it  has  been 


374  INFECTIONS  OF  WOUNDS 

shown  that  the  activities  of  the  poison  are  exercised  upon  the  central 
nervous  system,  especially  the  motor  ce^iters  of  the  spinal  cord  and 
the  medulla  oblongata,  causing  them  to  evince  a  state  of  hyperirrita- 
hility  and  of  hyper  sensitiveness  to  all  influences. 

As  first,  division  of  the  motor  nerves  and  curarization  of  tetanized 
muscles  abolishes  their  rigidity;  as  second,  despite  the  removal  of  the 
oerebrum,  muscle  spasm  may  still  be  provoked  (Brunner^°)  ;  and  as 
third,  destruction  of  a  segment  of  the  spinal  cord  is  followed  by  ces- 
sation of  spasm  in  the  muscle  group  it  supplies,  the  part  to  which  the 
poison  directs  its  activities  can  be  neither  the  periphery  nor  the  brain 
(v.  Leyden-'). 

The  cause  of  the  hinding  of  the  toxin  is  generally  attributed  to  its 
affinity  for  the  cells  of  the  central  nervous  system.  Wassermann  and 
Takaki^^  have  shown  that  tetanus  toxin  is  freely  neutralized  when 
mixed  with  hrain  suhstance.  Other  organs — liver  and  spleen,  for 
instance — show  no  such  neutralizing  capacity. 

Dissemination  of  the  toxin  in  the  substance  of  the  peripheral 
(motor)  nerves  may  be  regarded  as  proved  (Meyer  and  Ransom,^* 
Tiberti,-^  and  others).  The  local  contractions,  which  occur  in  the 
human — except  in  cephalic  tetanus,  and  at  times  develop  in  the 
animal  after  subcutaneous  (not  after  intravenous)  inoculation,  Stint- 
zing-"  explains  on  the  ground  that  the  poison  extends  along  the 
m-cshes  of  the  perineurium  and  attacks  that  portion  of  the  cord  con- 
cerned in  supplying  the  zone  of  the  port  of  entrance  of  the  infection. 
The  direct  action  of  the  toxin  on  the  muscles  is  assumed  from  the  con- 
clusions of  Zupnik,-^  who  worked  out  that  aspect  of  the  problem. 
Pochammer^®  considers  the  binding  of  the  toxin  in  the  peripheral 
nerve  substance  as  responsible  for  certain  pathological  changes  in  this 
location  which  isolate  motor  and  sensory  nerve  conduction,  and  thus 
stand  in  a  causative  relationship  to  the  local  spasm. 

When  an  animal  has  survived  tetanus,  its  hlood  is  immuyie  to  small 
doses  of  toxin.  This  immunity  may  be  increased  by  inoculation  until 
the  animal  is  capable  of  tolerating  pure  tetanus  toxin  or  virulent  cul- 
tures of  the  bacilli  themselves.  In  other  words,  it  has  hccome  tetanus 
immune,  and,  according  to  v.  Behring  and  Kitasato,^''  its  blood  is  anti- 
toxic, i.  e.,  capable  of  neutralizing  tetanus  toxin,  of  protecting  other 
animals  against  tetanus,  and  of  healing  those  in  which  the  disease  is 
already  developed.  The  bacilli  themselves  are  not  killed  by  the  anti- 
toxin, but  are  rendered  inert,  as  their  toxins  are  made  harmless  by 
it.     The  blood  serum  of  the  horse  is  capable  of  bestowing  upon  the 


TETANUS  375 

human  a  certain  protection  in  this  connection  and  is,  therefore,  iLsed 
as  a  therapeutic  scrum  {antitoxin). 

In  accord  with  previous  experiences,  it  is,  at  this  writing,  possible 
to  neutralize  the  tetanus  poison  present  in  the  circulation  by  the  intro- 
dxiciion  of  highly  concentrated  antitoxin.  If  the  body  of  the  infected 
person  is  not  overwhelmed  by  a  large  quantity  of  toxins,  it  is  justifi- 
able to  assume  that  repeated  injection  of  serum  makes  not  only 

THE  POISON  CIRCULATING  IN  THE  BLOOD  HARMLESS,  BUT  ALSO  THAT 
ENTERING  THE  PATHS  OF  THE  NERVE  TRUNKS  FROM  THE  WOUND  BEFORE 
THEY  REACH  THE  GANGLIONIC  CELLS  IN  THE  SPINAL  CORD  AND  THE 
MEDULLA  OBLONGATA.  WpIEN  THE  POISON  HAS  GAINED  ACCESS  TO  THE 
NERVOUS  SYSTEM  AND  IS  BOUND  THERE,  IT  IS  OUT  OF  REACH  OF  THE  ANTI- 
TOXIN IN  THE  BLOOD.  Although  the  antitoxin  does  not  enter  the  central 
nervous  system  from  the  blood,  it  may,  however,  be  directly  introduced 
there  by  subdural  or  intraventricular  injection  (Kocher^°).  The  em- 
ployment of  the  direct  injection  methods  are  more  successful  experi- 
mentally than  clinically  (v.  Torok^^). 

Antitoxin  should  he  administered  as  soon  after  the  diagnosis  is  made 
as  is  possible.  V.  Behring-^  states  that  the  best  results  are  attained 
when  this  is  done  within  thirty  hours.  The  injections  are  made  daily 
into  the  vein  (cephalic).  When  intravenous  injections  are  followed 
by  disturbing  symptoms,  the  serum  may  be  given  subcutaneously,  pre- 
ferably in  the  region  of  the  wound  (v.  Berhing-^).  In  tetanus  puer- 
peralis,  the  injections  may  be  made  into  the  vagina,  and  in  tetanus 
neonatorum  into  the  peritoneal  sac.  Pease^^  prefers  intramuscular 
injections.  Calmette^^  suggests  that  the  usual  methods  be  supple- 
mented by  strewing  dried,  powdered  serum  into  the  wound.  Kiister^* 
reports  a  favorable  result  following  injections  of  serum  into  nerve 
trunks  close  to  the  wound  of  entrance  of  the  infection.  Lexer^^  reports 
a  case  in  which  he  infliltrated  with  serum  the  exposed  nerve  ends  fol- 
lowing amputation,  and  also  injected  it  subcutaneously  twelve  hours 
after  the  onset  of  the  disease,  despite  which  there  was  a  fatal  out- 
come. 

The  dosage  of  serum  varies  with  dififerent  preparations.  Instruc- 
tions usually  accompany  each  output  and  should  be  carefully  followed. 
A  unit  is  a  quantity  of  serum  capable  of  neutralizing  poison  equal  to 
one  hundred  fatal  doses  to  a  guinea  pig  weighing  250  gms.  (about  8 
ounces) .  Usually  about  twenty  to  one  hundred  units  are  injected  sub- 
cutaneously each  day  and  the  same  quantity  into  the  lumbar  subdorsal 
space  every  other  day  until  improvement  is  definitely  established. 


376  INFECTIONS  OF  WOUNDS 

Despite  the  dangers  involved  in  the  procedure,  intraventricular 
(cerebral)  injections  of  5-10  c.cm.  and  subdural  spinal  injection  of 
20  c.cm.  (50-100  units)  of  serum  may  be  employed  in  cases  in  which 
the  toxms  have  reached  the  cerebrospinal  centers.  The  injections  are 
made  dail}^  or  on  alternate  days  and  should  be  slowly  executed  (fifteen 
to.  twenty  minutes)  with  the  view  of  preventing  disturbances  in  the 
intracranial  pressure. 

Injectio7is  into  the  lateral  ventricle  of  the  hrain  may  be  accom- 
plished by  the  method  of  Kocher,^°  who  selects  for  the  purpose  a  point 
on  the  skull  2.5  to  3  cm.  lateral  from  the  bregma  where  the  sagittal 
and  coronal  sutures  meet.  The  bone  is  exposed  through  a  short  in- 
cision and  a  small  opening  made  with  a  Doj^en  burr  (smallest  size) 
exposing  the  dura.  A  hollow  needle  is  pushed  through  the  dura  and 
on  into  the  brain  substance  (about  5  to  6  cm.)  until  the  leakage  of 
fluid  announces  its  arrival  in  the  ventricle.  The  injection  must  be 
made  slowly.  Tavel  recommends  (Directions  of  the  Swiss  Serum  and 
Vaccination  Institute)  that  the  puncture  be  made  3  cm.  from  the 
median  line  at  a  point  3  cm.  in  front  of  the  coronal  suture.  The  needle 
should  be  directed  toward  the  medulla,  and  when  advanced  3  cm. 
reaches  the  ventricle,  v.  Bergmann^*^  punctures  the  ventricle  from  in 
front,  entering  the  skull  at  a  point  close  to  the  inner  side  of  the 
tuberosity  of  the  frontal  bone.  Most  surgeons  turn  up  a  small  U-shape 
flap,  consisting  of  scalp  and  periosteum,  before  the  bone  is  attacked. 

The  spinal  injection  is  made  by  the  Quencke  method  of  lumbar 
puncture  (Part  IX).  The  patient  is  postured  on  the  left  side,  the 
needle  is  entered  between  the  spinous  processes  of  the  third  and  fourth 
lumbar  vertebrae  and  pushed  forward  in  a  slightly  upward  direction. 
AVhen  spinal  fluid  appears  at  the  proximal  end  of  the  needle,  the 
serum  is  slowly  injected  through  it. 

The  results  of  serum  treatment  are  not  readily  standardized,  since 
many  cases  recover  spontaneously.  That  it  has  not  been  curative  in 
the  severe  eases,  in  which  tetanus  developed  within  eight  days  after 
the  entrance  of  the  infection,  is  certain.  This  is  true  despite  the  fact 
the  antitoxin  is  known  to  have  permeated  the  entire  circulation,  as 
shown  by  its  presence  in  the  urine  (v.  Leyden^^). 

As  the  antitoxin  treatment  is  not  a  curative  certainty,  it  is  the  duty 
of  the  surgeon  to  employ  (beside  the  serum  treatment)  every  means  at 
his  disposal  to  attain  recovery  and  afford  relief  from  the  ghastly  suf- 
fering attendant  upon  the  affliction. 


TETANUS  377 

In  this  connection  the  most  important  measure  is  the  care  of  the 
wound.  As  toxins  are  constantly  absorbed  from  the  port  of  entrance, 
it  is  proper  to  prevent  this  by  promi^t  amputalioii  of  small  parts 
(fingers  and  toes),  and  excision  of  the  wound  when  its  location  permits. 
In  the  event  of  more  extensive  trauma,  especially  compound  com- 
plicated fractures,  it  is  proper  to  perform  major  amputations  when 
the  first  symptoms  of  tetanus  appear,  though  these  extreme  measures 
should  be  resorted  to  only  in  cases  in  which  the  brevity  of  the  period 
of  incubation  and  the  extent  and  character  of  the  injury  make  it 
proper  to  assume  that  the  infection  is  a  virulent  one.  McClintock  and 
Charles  and  Willard  Ilutchings,^'  in  their  experimental  observations, 
did  not  prove  the  value  of  amputation  as  a  measure  of  relief.  In 
wounds  of  the  torso,  all  necrotic  or  ragged  portions  of  tissue  must  be 
excised,  blood  clots  removed,  and  pockets  widely  split  and  drained, 
with  the  view  of  preventing  putrefactive  infection,  which,  as  already 
stated,  favors  the  invasion  of  tetanus  bacilli.  On  the  same  ground, 
the  open  aseptic  treatment  is  to  be  assiduously  exercised,  especially 
as  it  is  desirable  to  permit  the  entrance  of  air  into  wounds  of  this 
sort  with  the  view  of  obviating  anaeroMosis.  Foreign  bodies  present 
in  the  fresh  wound,  or  discovered  in  the  scars,  should  be  removed,  as 
they  are  often  inhabited  by  the  causative  bacilli  of  tetanus. 

Disinfection  of  the  wound  is  of  7io  value  (p.  59).  Cauterization  is 
objectionable,  as  the  resultant  scab  interferes  with  the  exit  of  exudate 
which  mechanically  removes  infective  substances. 

The  prophylactic  injection  of  tetanus  antitoxin  is  justified  in  all 
cases  of  wounds  soiled  with  street  dust,  manure,  or  earth,  especially  in 
regions  where  the  disease  is  endemic.  The  subcutaneous  injection  of 
twenty  units  of  antitoxin  is  a  routine  measure  in  cases  of  this  sort. 
Although  tetanus  occurs  in  cases  so  treated,  it  is  proper  to  state  that 
in  the  experience  of  the  writer  (attached  to  a  large  metropolitan  hos- 
pital), tetanus  is  now  rarely  seen,  while  before  the  use  of  antitoxin  as 
a  preventative  measure  became  en  vogue,  the  last  week  in  June  and 
The  first  three  weeks  in  July  of  each  year  (when  firearms  were  used  in 
connection  with  the  anniversary  of  the  Declaration  of  Independence  of 
rhe  United  States)  rarely  passed  without  the  occurrence  of  a  number 
of  cases.  As  the  prophylactic  activity  of  the  serum  lasts  only  two  and 
a  half  to  three  weeks,  and  the  period  of  incubation  of  tetanus  is  at 
times  sixty  days,  the  preventative  injection  should  be  repeated  weekly 
until  the  wound  is  healed. 

The  uncertainty  of  the  action  of  tetanus  serum  has  led  to  farther 


378  INFECTIONS  OF  WOUNDS 

efforts  to  conquer  the  disease.  In  1906,  Meltzer  and  Auer^*  found 
that  magyiesium  sulphate  solution  injected  into  the  lumbar  sac  pro- 
duced extensive  anesthesia,  and  more  or  less  paralysis  of  involuntary 
motion.  At  the  instigation  of  these  observers,  Blake^"  employed  the 
measure,  in  conjunction  with  the  serum  treatment,  for  the  relief  of 
pain  and  rigidity.  Blake's  case  recovered.  Subsequently  the  solution 
was  used  in  a  considerable  number  of  cases;  Lexer*°  reports  a  case 
of  recovery  in  which  the  period  of  incubation  was  only  six  days ;  in 
a  case  reported  by  Stromeyer,^^  the  injection  was  followed  in  fifteen 
minutes  by  sleep,  anesthesia  below  the  navel,  cessation  of  spasm,  and 
slowing  of  respiration.  If  the  contention  of  Zupnik,^'^  that  the  poison 
is  stored  in  the  muscles,  is  correct,  the  rationale  of  the  action  of  mag- 
nesium sulphate  solution  (aside  from  its  direct  effect  upon  the  cord) 
may  be  explained  on  the  ground  that  it  tends  to  prevent  liberation  of 
the  toxin  during  muscular  spasm.  The  techiiic  of  administration  con- 
sists of  lumbar  puncture,  lavage  of  the  canal  with  salt  solution  (to 
remove  the  toxin),  and  the  injection  of  about  15  c.cm.  of  15  per  cent 
magnesium  sulphate  solution.  If  the  solution  is  allowed  to  gravitate  to 
ihe  medulla,  respiratory  embarrassment  ensues,  therefore,  the  patient 
should  be  postured  in  a  manner  to  obviate  this.  In  several  instances, 
neglect  of  this  precaution  made  tracheotomy  and  artificial  respiration 
necessary.  Leyva,^^  working  with  the  French  army,  supplements  the 
serum  treatment  with  intravenous  injections  of  five  per  cent  sodium 
persulphate  solution,  using  three  doses  of  20  c.cm.  daily.  Leyva  claims 
that  it  controls  spasm,  and  states  that  recovery  occurred  in  the  cases 
in  which  it  was  used. 

The  symptomatic  treatment  is  directed  toward  control  of  the  reflex 
irritability  and  spasm,  especially  the  dangerous  contractions  of  the 
muscles  of  respiration.  For  the  purpose,  large  doses  of  morphin  and 
chloral  may  be  used.  Bergell  and  Levy'*^  (reaching  back  to  the  labors 
of  Claude  Bernard)  recommends  a  preparation  of  curare,  called 
curaril,  which  is  subcutaneously  injected  in  doses  of  0.2  c.cm.  every 
two  to  three  hours,  and  may  be  increased  gradually  to  2.4  c.cm. 
Laewen**  uses  curarin,  which  is  more  effective  in  doses  of  5  to  8  mg., 
injected  subcutaneously  and  increased  as  the  indications  arise.  This 
agent  has  also  been  introduced  intravenously.  As  spasm  interferes 
with  deglutition,  nourishment  must  be  given  by  the  rectum.  The 
heart's  action  may  be  sustained  by  the  administration  of  stimulants. 
The  environment  of  the  patient  should  be  arranged  to  obviate  disturb- 
ing elements. 


TETANUS  379 

BIBLIOGRAPHY 

1.  Carlo  and  Rattone.     Giomale  de  R.  Acad  d.  Torino,  1884. 

2.  NicOLAiK.     luautr.  Diss.  Gottiniien,  1885. 

3.  ROSENBACH.     Aix'h.  f.  klin.  Cliir.,  Bd.  34,  1886. 

4.  KiTASATO.     Deutseh.  med.  Woch.,  No.  31,  1889. 

5.  VOTALLER.     Zeitsch.  f.  Hyg.  xxvii. 

6.  Ferran-.     Zentrbl.  f.  Bakt.  xxiv,  No.  1. 

7.  Belfanti.     Arch,  per  le  sci.  med.  xvi. 

8.  Smith,  Brown,  and  Walker.     Jour.  Med.  Res.  N.  S.  ix,  1906. 

9.  Reiniiardt  and  Assim.     Zentrbl.  f.  Bakt.  Bd.  49,  Orig.,  1909,  with  lit. 

10.  Vaillard  et  Rouget.     Ann.  de  I'inst.  Pasteur,  1892. 

11.  Brieger  and  Cohn.     Zeitsch.  f.  Hvg.  xv. 

12.  Debraxd.    Ann.  de  I'inst.  Pasteur',  1890,  1902. 

13.  V.   LiXGELSHEni.     In  Kolle-'Wassermann   Handb.   der  path.   Mieroorg. 

Aufl.  2,  Bd.  4,  1912,  mit  lit. 

14.  Brauxx.     Chir.  Konq-.  Verb.,  1906,  i. 

15.  Koch.     Deutseh.  Zeitschr.  f.  Chir.  Bd.  48,  1898. 

16.  Philips.     The  Lancet,  1892. 

17.  Kuiix  and  Rossler.     Deutseh.  klin.  therap.  Woch.,  1906,  No.  46. 

18.  Rose.     Deutseh.  Chir.,  with  lit. 

19.  Klemm.     Same  as  No.  18. 

20.  Bruxxer.     Beitr.  z.  klin.  Chir.  Bd.  9-10,  and  12. 

21.  Blumexthal.     Spez.  Path.  u.  Tber.  v.  Xothnagel  Bd.  5,  1900. 

22.  V.  Leyden  and  Takaki.     Same  as  No.  21. 

23.  Wassermaxx  and  Takaki.     Berlin,  klin  Wocli.,  1898. 

24.  Meyer  and  Raxsom.     Arch.  f.  exper.  Path.  Bd.  49,  1903. 

25.  TiBERTi.     Zentrbl.  f.  Bakt.  Bd.  38,  Orig.,  1905. 

26.  Stixtzixg.     Greuzgeb.  d.  Med.  u.  Chir.,  1898,  Bd.  3;  also  Mlineh  med. 

Woch.,  1898. 

27.  ZuPXiK.     Deutseh.  med.  Woch.,  1905,  No.  50,  also  1908.  No.  26. 

28.  Pochammer.     Samml.  klin.  Vortr.,  1909,  Nos.  149-151. 

29.  V.  Behrixg  and  Kitasato.     Deutseh.  med.  Woeh.,  1890. 

30.  KOCHER.     Korrespdbl.  f.  Schweizer  Aertzte,  1912. 

31.  V.  ToROK.     Zeitsch.  f.  Heilkiinde,  1900,  Bd.  21. 

32.  Pease.     Anns.  Surg.,  1906,  Sept. 

33.  Calmette.     Acad,  des  sci..  May,  1903. 

34.  KuSTER.     Therap.  d.  Ge^enwart,  1907. 

35.  Lexer.     Allg.  Chir.  i,  Stuttgart,  1914. 

36.  V.  Bergmaxx.     The  Surg.  Treat,  of  Brain  Lesions,  Berlin,  1899. 

37.  McClixtock,  Charles  and  Willard  Hutchixgs.     Jr.  Inf.  Dis.  xiii, 

1913. 

38.  Meltzer  and  Auer.     Studies  of  Rockefeller  Inst,  v,  1906. 

39.  Blake.     Same  as  No.  38. 

40.  Lexer.     Therap.  d.  Gegenwart.,  1901. 

41.  Stromeyer.     Same  as  No.  13. 

42.  Ley\'A.     Surg.  Gyn.  Obst.  xxv,  1917. 

43.  Bergell  and  Levy.     Therap.  d.  Gegenwart.,  1904. 

44.  Laewex.     Mitthl.  a.  d.  Grenzgeb.,  Bd.  16,  1906. 


CHAPTER  XVI 

DIPHTHERIA 

So-called  diphtheria  of  the  mucous  membranes  and  of  the  skin  is 
a  fihrinous  inflammation  attended  with  necrosis.  This  peculiar,  at 
times,  superficial,  and,  at  times,  deep  inflammation,  is  not  caused 
by  diphtheria  bacilli  alone,  but  also  is  the  result  of  the  invasion  of 
typhoid  and  dj'sentery  bacilli,  of  streptococci  and  of  certain  chemical 
agents  (ammonia,  silver  nitrate,  etc.)  which  provoke  similar  changes 
in  the  various  mucous  membranes  of  the  bod3^  Diphtheria  bacilli 
are  (aside  from  the  comparatively  rare  instances  in  which  thej'  are 
responsible  for  wound  diphtheria)  the  excitants  provocative  of  the 
disease  known  as  epidemic  diphtheria  which  is  attended  by  changes 
in  mucous  membranes,  especially  those  of  the  upper  air  passages. 
The  bacilli  are,  however,  not  the  sole  causative  agents,  as  streptococci 
frequently  coexist  with  diphtheria  bacilli  and  may  indeed  be  alone 
responsible  for  fibriuonecrotic  inflammation  in  this  location  —  as  is 
often  seen  in  cases  of  scarlatina. 

The  diphtheria  bacillus  (Fig.  144),  first  described  by  Klebs^  (1883), 
and  obtained  in  pure  culture  by  Loffler^  (1884),  and  repeatedly 
submitted  by  him  for  verification,  was  finally  accepted  as  the  bacterio- 
logical causative  factor  in  diphtheria  after  the  work  of  Roux  and 
Yersin^  (1883),  although  Bretonneau  of  Tours  had  described  the 
disease  as  a  clinical  entity  in  1821. 

While  the  bacillus  diphtheriae  presents  certain  characteristic  ap- 
pearances which  facilitate  its  recognition,  it  is,  at  the  same  time,  sub- 
ject to  a  number  of  morphological  variations.  These  variations  are, 
to  a  limited  extent,  dependent  upon  the  age  of  the  culture  and  the 
constitution  of  the  medium  on  which  it  has  been  grown.  These  factors 
do  not,  however,  control  the  appearance  of  the  organism  with  any 
degree  of  regularity;  any  or  all  of  its  various  forms  may  occur  in 
one  and  the  same  culture.  It  is  likely  that  the  differences  in  appear- 
ance represent  stages  in  the  growth  and  degeneration  of  the  individual 
bacillus,  but  there  does  not  seem  to  be  any  reason  to  believe  that  there 

380 


DIPHTHERIA 


381 


is  a  definite  correlation  between  its  microscopical  form  and  its  biologi- 
cal characteristics,  such  as  virulence,  toxicit}^,  etc. 

The  bacilli  are  slender,  straight  or  slightly  curved  rods — 1.2  microns 
to  6.4  microns  in  length,  and  from  0.3  to  1.1  microns  in  breadth. 
They  are  rarely  of  uniform  thickness  throughout  their  length,  but 
show  club-shaped  thickened  areas  at  one  or  both  ends;  occasionally 
they  are  thickest  at  the  center  and  taper  toward  the  extremities.  When 
thickened  at  one  end  only,  a  slender,  wedge-shaped  edge  results. 
Such  forms  are  usually  straight,  of  smaller  size  than  their  consorts, 
and  stain  with  greater  uniformity.  Branched  forms  have  been  de- 
scribed by  some  observers. 

The  organism  stains  with  aqueous  anilin  dj'cs.     A  characteristic 

irregularity  of  staining 
which  is  of  great  aid  in  bac- 
terioscopic  diagnosis  is  best 
obtained  with  Loffler's  "al- 
kaline methylene  blue." 
Stained  with  Gram's 
method,  the  bacilli  retain  the 
gentian  violet.  Smears  from 
the  throat  or  from  cultures 
show  a  characteristic  group- 
ing of  the  bacilli.  They 
usually  lie  in  small  clusters, 
four  or  five  together,  parallel 
to  each  other  or  at  sharp 
angles.  Two  organisms  are 
often  attached  to  each  other 
by  their  corresponding  ends,  while  their  bodies  diverge  to  form  a  V 
or  Y  shape. 

The  diphtheria  bacillus  is  a  non-motile,  non-flagellated  non-spore 
forming  aerobe.  Its  preference  for  oxygen  is  marked,  but  it  will 
grow  in  non-aerobic  environment  in  the  presence  of  suitable  carbo- 
hydrates. It  does  not  liquefy  gelatin.  The  bacillus  grows  at  tem- 
peratures varying  between  19 °C  (66.2°F)  and  42 °C.  ( 107.6 °F.). 
Temperatures  above  37.5 °C.  (99.5°F.)  inhibit  its  growth  and  impede 
the  development  of  its  toxins.  Its  thermal  death  point  is  58°C. 
(136.4°F.)  for  ten  minutes.  Boiling  kills  it  in  about  one  minute. 
Low  temperature,  and  even  freezing  are  well  borne.  Desiccation  and 
exposure  to  light  are  not  fatal.     Sternberg*  has  found  it  alive  in 


Fig.    144. — ■  Diphtheria    Bacilli. 


382  INFECTIONS  OF  WOUNDS 

dried  bits  of  pseudomembrane  after  fourteen  weeks.  It  is  easily 
killed  by  chemical  disinfectants,  such  as  hydrogen  peroxid  which 
acts  very  rapidly. 

Cultivation  succeeds  on  most  laboratory  media,  though  the  most 
luxuriant  flora  is  obtained  on  Loffler's  beef  blood  scrum  under  aero- 
biosis.  At  the  end  of  twenty-four  hours,  small  (size  of  pinhead), 
grayish  white,  opaque  colonies  appear,  which,  when  magnified,  are 
seen  to  have  irregular  borders  and  are  easily  differentiated  from  the 
smaller  transparent  colonies  of  streptococci. 

For  diagnostic  purposes,  portions  of  membrane  may  be  removed 
from  the  lesion  with  a  sterile  forceps  and  gently  lavaged  in  sterile 
water  with  the  view  of  removing  superficial  contaminating  bacteria. 
The  specimen  is  then  ruhhed  on  the  oMique  surfaces  of  the  media  in 
test  tubes;  ten  or  more  hours  later,  a  dull,  yellowish  gray  streak  be- 
comes visible  upon  the  surface  of  the  media  from  Vv^hich  microscopic 
specimens  may  be  prepared.  The  bacilli  should  be  stained  by  Gram's 
method.  To  be  accurate,  and  for  the  purpose  of  differentiation  with 
regard  to  pseudodiphtheria  bacilli  (commonly  inhabiting  the  normal 
throat) ,  animal  inoculation  should  be  made. 

For  the  purpose  of  animal  inoculation,  guinea  pigs  may  be  satis- 
factorily used.  Ordinarily,  0.5  c.cm.  of  a  twfenty-four  hour  bouillon 
culture  is  fatal  (rabbits,  sheep,  young  dogs,  cattle,  horses,  chickens, 
pigeons,  and  cats  are  susceptible;  mice  and  rats  are  not).  In  accord 
with  the  virulence  of  the  inoculation,  animals  survive  subcutaneous 
injection  from  twenty-four  hours  to  two  weeks.  The  site  of  inocu- 
lation becomes  edematous.  Pleural  effusion,  fatty  degeneration  of 
the  internal  organs,  and  paralysis  of  various  kinds  also  develop. 

The  injectioyi  of  the  bacteria  free  filtrate  of  diphtheria  cultures 
passed  through  earthen  filters  is  followed  by  the  same  phenomena  as 
obtain  in  connection  with  the  bacilli  themselves;  therefore,  diphtheria 
bacilli,  like  the  excitants  of  tetanus,  are  toxic  bacteria  whose  patho- 
genesis is  chiefly  due  to  the  toxins  they  give  up,  rather  than  to  their 
local  multiplication  or  systemic  dissemination.  They  do,  however, 
contain  an  endotoxin  that  may  be  extracted  from  dead  bacilli  which  in 
experimental  work  is  exceedingly  toxic  and  readily  influenced  by  anti- 
toxin. 

Diphtheria  toxin  is  produced  in  man  or  in  animals  infected  with 
diphtheria  bacilli.  The  fact  that  diphtheria  was  attended  with  grave 
systemic  disturbances,  including  organic  degenerations,  and  that  the 
bacilli  could  be  demonstrated  in  the  local  lesion  only,  led  the  earliest 


DIPHTHERIA  383 

observers  to  suspect  that,  in  part  at  least,  the  infection  was  due  to 
a  soluble  and  diffusible  poison  or  toxin.  This  was  finally  proved  to 
be  the  case  by  Roux  and  Yersin^  in  1889,  who  proved  that  broth 
cultures  in  which  diphtheria  had  been  grown  for  varying  periods 
would  remain  toxic  for  guinea  pigs  after  the  organisms  themselves  had 
been  removed  from  the  culture  fluid  by  filtration. 

While  toxin  can  be  produced  with  almost  all  of  the  virulent  diph- 
theria bacilli,  there  is  a  great  A^ariation  in  the  speed  and  degree  of 
production,  dependent  upon  the  strain  of  the  organism  employed  and 
upon  the  ingredients  and  reaction  of  the  medium  upon  which  they  are 
grown.  One  of  the  strains  most  extensively  used,  not  onh^  in  this 
country  but  in  Europe  as  well,  is  that  known  as  "Culture  Americana" 
or  "  Park- Williams  Bacillus  No.  8,"  an  organism  isolated  by  Dr.  Anna 
Williams  of  the  New  York  Department  of  Health  in  1894. 

Because  of  the  severit}'  of  cases  of  diphtheria  in  which  the  excitants 
are  associated  with  streptococci,  it  is  probable  that  the  presence  of 
the  chain  cocci  tends  to  increase  the  toxin  producing  capacity  of  the 
diphtheria  bacillus  (Hibbert,^  Theobald  Smith,"  and  others). 

The  chemical  nature  of  dipJitheria  toxin  is  not  known.  Brieger  and 
Fraenkel"  regard  it  as  belonging  to  the  toxalbumin  group.  When  pre- 
cipitated with  alcohol  it  does  not  give  the  albumin  and  peptone  re- 
action, is  optically  inactive,  and  cannot  be  placed  in  any  of  the 
well  known  groups  of  organic  chemistry  (Brieger  and  Boor,^  Wasser- 
mann  and  Proskauer^).  Uschinsky^''  disputes  this;  his  contention  in- 
volves a  discussion  which  does  not  belong  here. 

The  hlood  serum  of  animals  which  have  survived  the  repeated  in- 
jection of  diphtheria  poison  and  are  thus  rendered  diphtheria  immune, 
protects  other  animals  against  the  disease  or  cures  those  already"  in- 
fected, because  it  contains  antitoxin  (v.  Bchring  and  Wernicke^^), 
the  activities  of  which  neutralize  the  toxins  in  the  blood  and  those  in 
the  body  cells.  The  diphtheria  bacilli  are  robbed  of  their  toxicity, 
rendered  harmless,  and  gradually  disappear  from  the  confines  of  their 
unwilling  host.  The  blood  serum  of  the  human,  recovered  from 
diphtheria,  contains  immunizing  power  for  animals  for  only  a  short 
period  of  time. 

For  the  purpose  of  preparing  antitoxin  for  the  human,  the  horse  is 
almost  entirely  used. 

Diphtheria  is  transmitted  from  one  individual  to  another  directly 
or  indirectly,  either  by  contact  or  by  droplet  infection — as  in  cough- 
ing, sneezing,  etc.     It  is  conveyed  hy  all  kinds  of  objects  such  as 


384  INFECTIONS  OF  WOUNDS 

napkins,  table  ware,  handkerchiefs,  etc.,  which  come  in  contact  with 
the  patient's  mouth  or  expectoration.  As  convalescents  and  even 
healthy  persons  harbor  diphtheria  bacilli  derived  from  the  patient, 
and  as  adults,  at  times,  are  afflicted  with  inflammations  in  the  mouth 
which  are  due  to  the  same  organism — devoid  of  fibrinous  exudate — 
the  disease  may  be  transmitted  by  persons  who  have  not  diphtheria. 
The  expectoration  of  the  patient  is  especially  dangerous  as  the  ex- 
citants remain  viable  for  from  three  to  four  months  when  dried — for 
instance,  in  expectorated  membrane. 

However,  not  all  persons  are  susceptible  to  the  disease.  Children 
are  predisposed  to  it ;  adults  develop  it  comparatively  seldom.  Chronic 
inflammatory  processes  of  mucous  membranes  also  predispose  to  its 
occurrence.  After  recovery,  immunity  lasts  only  a  few  months.  Con- 
tagion from  the  human  to  animals  is  doubtful. 

DIPHTHERIA  OF  MUCOUS  MEMBRANE 

Diphtheria  bacilli,  together  with  other  bacteria,  invade  the  upper 
air  passages  and  provoke  inflammation.  Usually,  the  tonsil  is  pri- 
marily invaded,  from  there  the  process  extends  to  the  fauces,  the 
pharnyx,  the  7iose,  the  larnyx,  the  trachea,  the  smaller  hronchi,  and 
the  middle  ear.  Primary  infection  of  the  nose  and  the  larynx  are  the 
least  frequent.  The  infection  has  primarily  invaded  the  vagina  and 
secondarily  appeared  in  the  esophagus  and  the  stomach. 

Invasion  of  mucous  memhranes  hegiyis  with  constitutional  and  local 
manifestations.  The  onset  is  often  sudden  and  is  attended  with  high 
fever,  delirium,  etc.,  and  not  infrequently,  with  malaise,  chills  and 
anorexia.  The  local  manifestations  are  of  course  dependent  upon  the 
seat  of  the  infection.  Pharyngeal  diphtheria  begins  with  dysphagia ; 
that  of  the  larjiyx  with  hoarseness,  coughing,  dyspnea ;  and  that  of  the 
nose  with  a  sanguinopurulent  discharge. 

The  invaded  mucosa  is  at  first  strongly  inflamed.  Soon  small,  white, 
slightly  elevated  flecks  make  their  appearance  on  the  pharynx  or 
tonsil ;  as  these  consist  of  fibrinous  exudate  deposited  on  areas  denuded 
of  epithelium,  they  are  easily  wiped  off.  These  spots  gradually  spread 
and  thicken  by  the  deposit  of  additional  layers  of  fibrin,  so  that,  in  a 
few  days — for  instance,  in  pharyngeal  diphtheria —  the  tonsil,  the 
arch  and  pillars  of  the  fauces,  the  uvula,  and  the  entire  pharyngeal 
wall  is  covered  with  grayish  white  or  grayish  yellow  deposit.  At  the 
same  time,  the  process  extends  deeper  into  the  mucosa  which,  after  the 


DIPHTHERIA  385 

removal  of  the  exudate,  is  denuded  of  epithelium  only,  and  heals 
without  scarring.  Later,  or  in  the  more  virulent  eases,  the  connective 
tissue  of  the  mucosa  is  invaded;  the  membrane  is  detached  with 
difficulty  and  its  removal  is  attended  with  bleeding  and  loss  of  sub- 
stance. Upon  this  anatomical  difference  rested  the  older,  now  properly 
disregarded,  division  of  epidemic  diphtheria  into  croupous  and  diph- 
theritic infection,  or  into  croup  and  diphtheria.  It  is  now  known  that 
these  are  simply  degrees  of  severity  of  the  same  process.  In  a  general 
way  it  ma}^  be  said  that  the  exudate  of  diphtheria  clings  more  firmly 
to  flat  epithelium  than  it  does  to  the  ciliated,  the  cilia  of  the  latter 
hindering  the  firm  attachment  of  the  fibrinous  deposit. 

In  this  connection  it  is  proper  to  allude  to  inflammatory  conditions 
of  the  pharynx,  attended  with  the  deposit  of  fibrinous  exudate,  which 
are  not  due  to  Loftier 's  bacillus  and  frequently  accompany  acute  in- 
fectious diseases,  such  as  exanthemata,  t^i^hoid  fever,  pertussis,  pneu- 
monitis, etc.  The  condition  is  called  secondary  croup,  or  better, 
diphtheroid. 

An  effort  has  been  made  to  characterize  the  local  manifestations  of 
diphtheria,  as  diphtheritis,  but  it  has  not  been  generally  accepted. 

Forcible  detachment  of  the  false  membrane  is  usually  followed  by 
the  deposit  of  new  fibrin,  and  more  or  less  necrosis  of  underlying 
tissue;  when,  however,  the  membrane  is  spontaneously  exfoliated,  the 
loss  of  substance  is  slight  except  in  the  tonsil,  where  scar  formation 
may  be  extensive. 

Separation  of  the  memhranoiis  deposit  in  the  adult  begins  early 
(on  the  second  da}')  ;  in  children,  usually  not  until  after  the  seventh 
day  (Rumpf^-). 

Deep  ulcerations  extending  to  the  cartilege  and  bones  (nose  and 
larynx)  are  rare  and,  w'hen  present,  are  due  to  the  coexistence  of  other 
bacteria  (pyogenic  and  putrefactive)  which  produce  putrid  disinte- 
gration and  fibrinonecrotic  destruction  of  greater  or  less  areas  of 
mucous  membranes.  Repair  of  these  areas  in  the  larnj-x  may  produce 
cicatricial  obstruction. 

The  submucous  tissue  takes  part  in  the  process  in  the  form  of  an 
inflammatory  edema  which,  at  times,  goes  on  to  phlegmon  and  subse- 
quent abscess  formation  when  pyogenic  bacteria  are  concerned  in  the 
invasion ;  although  this  condition  may  occur  in  uncomplicated  diph- 
theria bacillus  infection. 

The  contiguous  lymph  nodes  are  always  swollen  and,  when  sectioned, 
display  small,  grayish  white  necrotic  areas;  they  rarely  suppurate. 


386  INFECTIONS  OF  WOUNDS 

The  blood  and  vital  organs  contain  diplithei'ia  bacilli  in  a  nmch 
greater  number  of  instances  than  has  heretofore  been  believed. 

Microscopically,  freshly  attacked  areas,  denuded  of  epithelium,  are 
seen  covered  with  a  layer  of  netlike  fibrin,  the  interspaces  of  which 
contain  epithelial  cells  in  a  state  of  hyaline  degeneration  and  leuko- 
cytes, and  whose  slender  fibrilae  merge  into  the  inflamed,  edematous 
connective  tissue  of  the  contiguous  mucosa. 

Subsequently,  exudation  accumulates  in  layers.  The  oldest  and 
most  superficial  layer  consists  of  epithelial  detritus  and  fibrin  and 
contains  a  large  quantity  of  saprophytes ;  next  comes  a  layer  of  closely 
meshed  fibrin,  and  then  one  consisting  of  widely  spaced  younger 
fibrin  which  contains  leukocytes.  The  first  layer  is  the  residence  of 
the  diphtheria  bacilli,  the  last  is  intimately  associated  with  the  inflamed, 
infiltrated  connective  tissue. 

The  course  of  the  disease  is  acute  and  results  in  recovery  or  death  in 
about  one  week. 

The  severity  of  the  affliction  depends  upon  the  character  of  the 
epidemic,  the  site  and  extent  of  the  process,  and  the  presence  of  mixed 
infection.  Laryngeal  diphtheria  is  more  menacing  than  that  limited 
to  the  pharnj-x  and  usually  runs  an  unfavorable  course,  especially 
when  accompanied  by  the  simultaneous  invasion  of  streptococci. 

The  mortality  in  children  is  high ;  those  under  one  year  of  age  almost 
always  die ;  as  age  increases  the  death  rate  diminishes. 

The  causes  of  death  are  many  and  are  connected  with  the  local 
course,  the  degree  of  toxicity,  and  the  complications. 

The  changes  in  the  mucosa  itself  cause  death  (especially  in  young 
children)  by  stenosis  of  the  larnyx  due  to  the  accumulation  of  mem- 
brane, of  secretion  and  swelling  ot  the  mucosa.  Suffocation  may  be 
obviated  by  tracheotomy,  but  this  measure  is  only  effectual  when 
not  postponed  until  severe  obstructive  dyspnea  has  developed  and 
when  the  process  is  limited  to  the  larynx.  When  the  exudate  extends 
into  the  bronchi  and  their  subdivisions,  no  efforts  at  relief  are  crowned 
with  success. 

The  toxic  general  infection  acts  primarily  upon  the  heart  (the  pulse 
is  slow  and  intermittent).  At  times,  in  a  few  days  after  the  onset  of 
the  disease,  a  fatal  outcome  results  from  paralysis  of  the  vagus,  fatty 
degeneration  of  heart  muscle  fiber,  or  from  paralysis  of  the  cardiac 
ganglia ;  in  some  instances,  cardiac  insufficiency  during  convalescence 
i^  fatal. 

The  toxins  are  also  responsible  for  more  or  less  serious  complies- 


DIPHTHERIA  387 

tions,  such  as  acute  nephritis  and  diphtheritic  paralysis.  The  latter 
is  probably  caused  by  an  ascending  toxic  neuritis  with  secondary  cen- 
tral degeneration  (Rainy^^).  The  paralysis  is  divided  into  an  early 
paralysis  of  the  soft  palate-,  which  occurs  in  severe  eases,  and  a  late 
form  developing  in  the  second  or  third  week  and  recovering  spon- 
taneously. The  muscles  of  the  palate  and  pharynx,  with  disturbances 
of  speech  and  deglutition,  loss  of  tendon  reflexes,  and  impairment  of 
the  ocular  muscles — including  accommodation,  are  frequent  complica- 
tions. In  a  certain  number  of  cases,  the  vocal  cords,  the  diaphragm, 
the  muscles  of  the  trunk,  and  the  extremities  are  paralyzed.  Sensory 
conduction  is  rarely  impaired.  Hemiplegia  follows  cerebral  embo- 
lism or  rupture  of  a  blood  vessel  in  very  toxic  cases. 

Brmichopncumoiiitis  due  to  aspiration  of  infected  membrane,  or 
provoked  by  direct  extension  from  above,  and  coincident  streptococcus 
invasions,  are  not  uncommon  and  are  exceedingly  dangerous  compli- 
cations. Poly-infections  not  only  add  to  the  local  disturbances  by 
causing  necrosis  and  phlegmon  but  they  contribute  largely  to  the 
severity  of  the  general  infection.  Usually  the  process  takes  on  the 
form  of  a  putrid  general  infection;  locally,  an  extensive  disintegration 
of  the  mucosa  with  dirty  brown  deposits  and  fetid  secretions  takes 
place,  which  is  attended  with  a  low  grade  of  fever  (at  times  sub- 
normal temperature),  prostration,  cardiac  feebleness,  hemorrhages  into 
the  skin,  arthritis,  endocarditis,  and  nephritis  (putrid  diphtheria). 
The  assumption  that  these  manifestations  are  due  to  the  added  pres- 
ence of  putrefactive  poisons  and  of  streptococci  is  shown  by  the  fre- 
quenc}'  with  which  the  latter  are  found  in  the  blood  (Nowak^*)  and 
the  fact  that  the  emplo}Tiient  of  antitoxin  is  ineffectual.  Cases  of  this 
sort  usually  result  fatall}^  in  a  few  days. 

In  considering  the  local  treatment  of  diphtheria  of  the  mucosa,  it 
is  necessary  to  bear  in  mind  that  the  application  of  chemical  agents 

AND  mechanical  IRRITATION  DAMAGES  ONLY  THE  ALREADY  INFLAMED 
MUCOSA,  AND  TENDS  TO  SPREAD  THE  INFECTION  AND  PROMOTE  ABSORPTION 
OP  THE  TOXINS. 

The  most  important  therapeutic  measure  consists  of  the  adminis- 
tration of  antitoxin. 

Antitoxin  is  injected  into  the  subcutaneous  tissue  of  the  thorax, 
buttock,  or  thigh.  The  dosage  is,  of  course,  in  accord  with  the 
preparation  which  varies  with  its  source.  This  aspect  of  the  prob- 
lem cannot  be  discussed  here  for  that  reason.  It  is,  however,  not 
out  of  place  to  suggest  that  timidity  as  to  dosage  is  undesirable  and. 


388  INFECTIONS  OF  WOUNDS 

ABOVE  ALL,  IT  MUST  BE  REMEMBERED  THAT  THE  EARLIER  THE  TREATMENT 
IS  EMPLOYED,  THE  MORE  LIKELY  IS  A  SUCCESSFUL  OUTCOME. 

Prophylaxis  is  achieved  by  the  use  of  immunizing  injections,  the 
dosage  of  which  is,  as  stated  above,  determined  in  accord  with  the 
preparation  used. 

In  most  cases,  the  therapeutic  injection  of  antitoxin  is  followed  hy 
rapid  improvement.  The  inflammation  is  arrested,  the  membranous 
exudate  separates  and  is  expelled,  slight  symptoms  of  laryngeal 
stenosis  disappear,  the  swollen  mucosa  recedes,  and  the  systemic  dis- 
turbances fade. 

The  mortality  of  diphtheria  has  become  less  since  the  employment 
of  antitoxin.  Kossel  states  that  the  average  deaths  from  diphtheria 
in  100,000  persons,  have  fallen  in  a  year,  from  106  to  44. 

The  injection'  of  antitoxin  is,  at  times,  followed  (in  from  ten  to 
twelve  hours)  by  urticaria  or  the  appearance  of  a  rash  not  unlike 
that  of  measles,  by  swelling  of  lymph  nodes,  arthralgia,  fever,  and 
leukopenia  (serum  sickness  —  see  anaphylaxis).  These  manifestations 
usually  follow  repeated  injections — rarely  the  first,  especially  if  the 
sequential  injections  are  given  after  an  interval  of  from  three  to  six 
weeks.  Repeated  administrations  should,  therefore,  be  made  at  short 
intervals. 

In  severe  cases,  attended  with  gangrenous  destruction  and  strepto- 
coccus infection  (the,  so-called,  putrid  diphtheria),  the  antitoxin 
treatment  fails.  In  these  cases  Emmerich^^  recommends  the  local 
application  of  concentrated  pyocyanase  solution  of  which  3-4  c.cm. 
are  sprayed  several  times  daily  into  the  pharynx.  Pyocyanase  has 
the  power  to  bind  not  only  the  toxin  of  diphtheria  but  also  to  destroy 
its  bacilli  and  the  pyogenic  excitants.  It  has  a  solvent  effect  upon 
the  exudate  and  may  quite  properly  be  used  in  conjunction  with  the 
serum  treatment. 

The  systemic  treatment  should  be  executed  in  the  manner  usually 
employed  in  connection  with  acute  infectious  diseases. 

DIPHTHERIA  OF  THE  SKIN 

At  the  end  of  a  few  days,  it  is  not  uncommon  to  see  the  edges  of  the 
tracheotomy  wound  become  strongly  inflamed  and  then  undergo 
gangrenous  disintegration.  Usually  the  dead  tissue  soon  sloughs,  sep- 
arates, and  healing  by  granulation  takes  place;  at  times,  however, 
the  necrosis  of  tissue  extends  in  all  directions,  exposing*  the  trachea 


DIPHTHERIA  389 

and  the  two  sternomastoid  muscles,  and  considerable  loss  of  substance 
takes  place  before  complete  cicatrization  is  accomplished. 

This  acute  progressive  wound  gangrene  may  be  the  result  of  the 
activities  of  the  diphtheria  bacilli  which  produce  a  superficial  coagu- 
lation necrosis  and  a  strong  inflammatory  reaction.  The  surface  of 
the  wound  is  covered  with  a  dirty,  reddish  gray,  firmly  adherent  de- 
posit; later,  the  subjacent  tissues  undergo  putrid  disintegratimi. 
When  systemic  disturhances  are  present,  they  do  not  differ  from 
those  attendant  upon  infections  of  mucosa.  Billroth  speaks  of  having 
seen  paralysis  and  also  describes  the  occurrence  of  skin  diphtheria  in 
connection  with  epidemics  observed  during  pre-aseptic  days  in  hos- 
pitals for  children. 

At  this  writing  (except  in  connection. with  tracheotomy)  this  form 
of  diphtheria  is  rarely  seen;  however,  Brunner's^^  bacteriological 
investigations  have  substantiated  the  observations  of  previous  workers. 
It  has  also  been  shown  that  Loffler's  bacilli  are  present  in  wounds 
exhibiting  fibrinous  deposits  (Schottmiiller^^),  though  their  pres- 
ence need  not  be  attended  with  sj^stemic  disturbances ;  when  found 
associated  with  pyogenic  bacteria  (Brunner,^''  TaveP*)  they,  of  course, 
do  not  have  an  opportunity  to  display  distinctive  systemic  symptoms. 

Recognition  of  wound  diphtheria  in  mild  cases  is  not  an  easy 
matter,  since  the  processes  provoked  by  many  of  the  excitants  are 
attended  with  exudation  and  tissue  necrosis  closely  resembling  infec- 
tion with  Loffler's  bacillus.  In  severe  cases  the  clinician  would  be 
likely  to  think  first  of  noma  and  hospital  gangrene.  Of  course, 
bacterioscopic  examination  determines  the  diagnosis. 

The  local  treatment  encompasses  the  same  precautions  dwelt  upon 
in  connection  with  diphtheria  of  mucous  membranes.  The  use  of 
unconfined  moist  dressings  aids  in  separating  the  exudate.  The 
topical  application  of  antitoxin  is  of  distinct  value. 

The  prevention  of  wound  diphtheria  in  connection  with  tracheotomy 
is  accomplished  by  light  tamponade  with  iodoform  gauze  and  frequent, 
gentle  mechanical  cleansing. 

Occasionally  a  small  wound  is  the  port  of  entrance;  of  a  severe  pro- 
gressive serous  phlegmon  of  the  suhcutaneous  tissue  due  to  diphtheria 
bacillus  invasion.  The  first  case  (which  resulted  fatally)  w'as  reported 
by  Giinther.^''  Ehrhardt-°  reports  a  similar  case  and  Hammerschmidt-^ 
found  the  bacillus  in  the  pus  of  skin  blebs  in  a  ease  of  diphtheria  of 
the  pharynx.  Recently,  wound  diphtheria  has  been  found  to  be  less 
rare  than  has  been  heretofore  believed.     It  has  been  observed  as  a 


390  INFECTIONS  OF  WOUNDS 

secondary  post  operative  infection  (by  the  writer)  in  two  cases  (both 
fatal),  one  a  perineorrhaphy;  the  other  followed  ligature  of  the 
external  carotid  artery,  preliminary  to  excision  of  the  tongue.  It  is 
worthy  of  note,  that  in  the  latter  case  the  wound  in  the  neck  was 
infected  as  stated,  while  the  one  in  the  mouth  remained  clean. 

BIBLIOGRAPHY 

1.  Klebs.     Verb.  d.  3te.  Kong.  f.  inn.  MecL,  Wiesbaden,  1883. 

2.  LoFFLER.    Mitthl.  a.  d.  kais.  Gesundheitsamt,  1884. 

3.  Roux  and  Yersin.     Ann.  de  I'inst.  Pasteur,  1888-1889. 

4.  Sternberg.     Manual  of  Bacteriology. 

5.  HiBBERT.     Zeitsch.  f.  Hyg.  xxix,  1898. 

6.  Smith.     Med.  Rec.  May,  1896. 

7.  Brieger  and  Frabnkel.     Berlin,  klin.  Woeh.,  xi-xii,  1889. 

8.  Brieger  and  Boer.     Deutsch.  med.  Woch.,  1896. 

9.  Wassermann  and  Proskauer.     Deutsch.  med.  Woch.,  1891. 

10.  UscHiNSKY.     Zentrbl.  f.  Bakt.,  xxi,  1897. 

11.  V.  Behring  and  Wernicke.     In  Kolle- Wassermann  Handb.  d.  path. 

Microorg.  Aufl.  ii,  Bd.  5,  1913. 

12.  RuMPF.     Handb.  d.  prak.  Med.  Stuttgart,  Bd.  5,  1901. 

13.  Rainy.     Jr.  of  Path,  and  Bact.,  1900. 

14.  NowAK.     Zentrbl.  f.  Bakt.  Bd.  19,  1896. 

15.  Emmerich.     Miinch.  med.  Woch.,  1907. 

16.  Brunner.     Berlin,  klin.  Woch.,  1893-1894,  and  Frauenfeld,  1898. 

17.  ScHOTTMiJLLER.     Deutscb.  med.  Woch.,  1895. 

18.  Tavel.     Deutsch.  Zeitscb.  f.  Cbir.  Bd.  60,  1901. 

19.  GiJNTHER.     Zentrbl.  f.  Bakt.  Grig.  Bd.  43,  1907. 

20.  Ehrhardt.     Miinch.  med.  Woch.,  1907. 

21.  Hammerschmidt.    Zeitsch.  f.  Hyg.,  etc.,  Bd.  53,  1905. 


CHAPTER  XVII 

ANTHEAX 

Especial  interest  attaches  to  the  anthrax  bacillus,  since  it  was  the 
first  microorganism  shown  to  bear  a  specific  causative  relationship  to 
an  infectious  disease.  Upon  this  foundation  was  built  the  edifice  of 
modern  bacteriology.  The  bacillus  was  first  observed  in  the  blood  by 
Pollender^  in  1849,  and  independently  by  BrauelP  in  1857.  In  1865 
Devaine^  produced  the  infection  in  animals  with  blood  containing  the 
bacilli  and  suggested  their  etiological  connection  with  the  disease. 
Koch,*  in  1876,  isolated  the  bacillus,  cultivated  it,  and  produced 
anthrax  by  experimental  inoculation. 

The  anthrax  hacilliis  (Fig.  145)  is  a  straight  rod,  5-10  microns 
in  length,  1-3  microns  in  width.  It  is  non-motile.  In  preparations 
made  from  the  blood  of  an  infected  animal,  the  bacilli  are  usually  single 
or  in  pairs.  Grown  on  artificial  media,  they  form  long  chains.  Unlike 
most  bacilli,  their  ends  are  cut  off  square.  In  a  chain,  the  sharp  corners 
only  touch  each  other,  leaving  an  intermediate  oval  chink  between  the 
ends  of  the  organisms.  Therefore,  the  appearance  of  a  chain  of 
anthrax  bacilli  quite  properly  may  be  compared  to  a  rod  of  bamboo. 
Oxygen  is  necessary  to  the  formation  of  spores. 

Staining  is  readily  accomplished  with  all  the  anilin  dyes,  with  hema- 
toxylin, and  with  Gram.  When  stained,  the  bacilli  are  seen  to  be 
enmantled  by  a  translucent  area  called  the  capsule,  and  also  to  contain 
in  their  bodies  similar  oval  spaces.  These  oval  spaces  are  the  spores 
of  the  bacilli  and  are  found  in  almost  all  of  them.  The  spores  are 
liberated  upon  the  disintegration  of  the  rods.  "When  a  bacillus  spores, 
in  a  fresh  culture  medium,  it  swells  up  and  the  spore  slips  out  at  one  of 
its  poles.  Because  of  the  great  resistance  of  the  anthrax  hacilli,  they 
are  used  as  a  standard  in  sterilization;  steam  at  100° C.  (212°F.)  kills 
them  in  five  minutes,  dry  heat  at  140'C.  .(284°F.),  in  three  to  four 
hours. 

The  spores  are  best  stained  by  the  method  of  Klein.  The  material 
containing  the  spores  is  mixed  with  physiological  salt  solution ;  this  is 

391 


392 


INFECTIONS  OF  WOUNDS 


diluted  in  equal  quantity  with  filtered  Zielil's  carbolfuchsin  and 
warmed  to  steam  production;  of  this,  a  few  drops  are  placed  on  a  cover 
glass,  dried,  decolorized  with  sulphuric  acid,  washed  in  water,  and 
stained  with  a  dilute  methylene  blue  for  from  three  to  four  minutes 
(Sobernheim^). 

CuUivation  of  anthrax  bacilli  on  gelatin  is  characteristic,  less  so  on 
agar.  It  succeeds  best  in  the  presence  of  ox^^gen,  though  it  is  faculta- 
tively anaerobic.  The  optimum  temperature  for  its  growth  ranges 
around  37.5°C.  (99.5°F.).  It  is  not  particularly  susceptible  to  ther- 
mic variations,  growing  luxuriantly  at  12 °C.  (53.6°F.)  or  at  45  °C. 
(113°F.).  By  continuous  cultivation  at  these  extremes,  the  bacillus 
soon  adapts  itself  to  the  condi- 
tions and  attains  luxuriant  flora 
(Dieudonne''). 

On  gelatin,  the  bacillus  forms 
small,  dark  gray  points,  which, 
on  close  scrutiny,  are  seen  to 
have  wavy  edges,  and  to  send  out 
curly  projections  (medusa 
form)  ;  in  stah  cultures,  the  per- 
pendicular growth  sends  out 
bristle-like  spicula.  The  gelatin 
is  finally  liquefied. 

In  milk,  when  associated  with 
the  'bacillus  pyogenes,  the  an- 
thrax bacillus  dies,  as  the  former 
produces  a  ferment-like  sub- 
stance {pyocyanase)  which  dissolves  the  excitant  of  anthrax  (Em- 
merich^). In  animals,  staphylococci  and  streptococci  also  take  an 
antagonistic  attitude  toward  anthrax  bacilli. 

For  purposes  of  inoculation,  white  mice,  guinea  pigs,  and  rabbits 
are  particularly  useful.  "Whether  the  material  inoculated  is  free  of 
spores  or  not,  these  animals  die  after  infection  of  small  skin  wounds 
in  from  one  to  three  days,  at  which  time,  great  quantities  of  bacilli  may 
be  found  in  the  blood  vessels  of  the  vital  organs.     The  absorption 

OF  THE  excitants  IN  MICE  IS  SO  RAPID  THAT  AMPUTATION  OF  THE 
INFECTED  LIMB,  WITHIN  TEN  MINUTES  AFTER  INOCULATION,  DOES  NOT 
SUFFICE  TO  OBVIATE  A  FATAL  RESULT,  AND  IN  HALF  AN  HOUR  THE  PRES- 
ENCE   OF   THE    BACILLI    IN    THE    VITAL    ORGANS    MAY    BE    DEMONSTRATED. 

Crcneral  infection  may  follow  the  simple  rubbing  of  the  uninjured 


Fig.  145. —  Anthrax  Bacilli. 


ANTHRAX  393 

skin  with  a  virulent  anthrax  culture.  The  bacilli  g^ain  access  to  the 
gastro-intestinal  canal  through  the  mouth,  are  absorbed,  and  cause 
fatal  general  infection  (it  is  necessary  that  spores  be  present). 

The  lung  is  invaded  by  the  inhalation  of  dried  spores. 

Specific  toxins  of  the  anthrax  bacilli  have  not  been  discovered 
(Sobernheim^).  Trincas^  reports  having  developed  a  toxin  by  the 
action  of  leukoc3'tes  on  bacilli  that  were  devoid  of  spores. 

With  regard  to  virulence,  Preisz^  states  that  bacilli  with  heavy  cap- 
sules are  more  resistant  than  those  whose  covering  is  thin  and  easily 
dissolved. 

All  that  is  known  regarding  the  habitat  of  anthrax  bacilli,  outside 
the  body,  is  that  when  the  spores  are  deposited  upon  the  ground  with 
the  excrement  of  an  animal,  especially  on  a  moist  surface,  they  live 
for  a  long  time  (two  to  three  years)  and  may  be  disseminated  in  many 
v/a3^s  —  by  animals,  humans,  rain,  flood,  etc. —  reaching  new  grazing 
areas  and  thus  gain  access  to  the  digestive  tract  of  other  animals. 
Cattle  often  develop  the  infection  in  the  gastro-intestinal  canal,  rarely 
in  skin  wounds,  and  never  in  the  lungs.  Birds,  rats,  dogs,  and  pigs 
are  immune. 

Susceptible  animals  may  be  immunized  by  the  method  of  Pasteur. 
Blood  serum  of  immunized  animals  has  been  of  value  in  rendering 
other  animals  immune,  and  in  the  cure  of  infected  ones.  Sobern- 
heim^°  uses  immune  serum  in  conjunction  with  weakened  anthrax 
bacilli  for  both  passive  and  active  immunity.  Sclavo  and  Mendez^^ 
have  successfully  used  the  serum  treatment  in  the  human. 

The  surgeon  is  especially  interested  in  external  anthrax  infection, 
which  is  the  form  in  which  it  is  most  frequently  encountered.  The 
infection  invades  a  wound  or  may  begin  in  a  hair  follicle,  and  is  most 
often  met  with  in  persons  coming  in  contact  with  the  cadaver  or  the 
excreta  of  animals  harboring  the  excitants,  therefore,  unprotected 
portions  of  the  body  are  commonly  attacked.  W.  Koch^^  reported 
that,  out  of  1,077  cases,  in  490  the  head  was  invaded,  and  in  370  the 
upper  extremities  and  hands.  Probably  the  hands  carry  the  infection 
to  the  face  and  other  portions  of  the  body  where  minute  scratches, 
rhagades,  etc.,  may  be  the  port  of  entrance.  In  addition  to  this,  the 
infection  is  conveyed  by  the  hides  and  hairs  of  animals  (horsehair, 
fur  caps,  pelts,  sandals,  etc.),  and  the  bites  of  fleas,  flies,  mosquitoes, 
etc.,  though  it  is  quite  possible  that  the  scratching,  provoked  by  the 
itching,  with  fertilized  fingers  is  really  the  cause  of  the  infection. 

Internal  anthrax  develops  in  the  lung  after  inhalation  of  spores 


394  INFECTIONS  OF  WOUNDS 

contained  in  dust.  This  form  of  anthrax  affects  workers  in  paper 
mills  who  handle  rags.  The  disease  takes  on  the  character  of  a  double 
pneumonitis  and  pleiiritis,  runs  a  severe  course  with  symptoms  of  a 
general  infection  and  ends  fatally  in  a  few  days  (wool  sorters* 
disease). 

The  second  form,  intestinal  anthrax,  is  rare  and  is  attended  with 
hemorrhagic  foci,  especially  in  the  mucosa  of  the  small  gut,  which 
undergo  gangrenous  disintegration.  The  lesions  are  the  result  of  the 
ingestion  of  food  fertilized  with  anthrax  bacilli.  In  the  mouth,  the 
infection  follows  contact  with  the  fingers.  The  intestinal  infection  is 
attended  with  the  clinical  picture  of  a  severe  general  infection. — 
bloody  diarrhea,  peritonitis,  and  finally  collapse  and  death. 

Both  forms  of  internal  anthrax  may  accompany  the  external,  either 
because  of  a  common  source  of  infection  or  as  the  outcome  of  embolic 
dissemination  of  the  disease  (Koch^-). 

External  anthrax,  in  rare  instances,  appears  secondary  to  an  inter- 
nal infection  as  an  embolic  process  attended  with  multiple  pustules, 
and  takes  on  either  the  form  of  a  carbuncle  or  of  edema  of  the  skin, 
though  it  may  appear  upon  the  mucosa  of  the  nose  and  mouth. 

Anthrax  carbuncle  (Fig.  146)  begins  as  a  small,  red,  itching  spot 
which  in  one,  two,  or  more  days  develops  a  small  bluish  black  blister 
filled  with  serosanguineous fluid  {anthrax  pustule,  or  pustula  maligna). 
Very  soon,  especially  when  the  blister  is  scratched  or  emptied  by 
pressure,  a  discolored  scab  forms  which,  owing  to  the  swelling  of  the 
surrounding  inflamed  skin,  appears  depressed.  The  blackened,  gan- 
grenous scab  varies  in  size  from  a  twenty-five  cent  piece  to  a  silver 
dollar,  the  infiltrate  being  as  large  as  an  English  walnut.  The  red- 
dened area  is  the  site  of  additional  smaller  serosanguineous  blisters, 
upon  which  scabs  are  also  formed.  The  bacilli  of  anthrax  may  be 
found  in  the  fresh  pustules  and,  at  times,  in  their  fluid  contents,  and 
may  be  identified  under  the  microscope  or  following  injection  into 
trial  animals.  When  pyogenic  bacteria  are  also  present,  the  blisters 
contain  a  purulent  exudate. 

Anthrax  edema  often  consorts  the  carbuncular  form  on  the  face, 
so  that  a  pustule  located  in  the  vicinity  of  the  mouth  causes  edematous 
infiltration  of  the  cheek  and  neck.  The  infiltrated  area  extends  rap- 
idly over  a  wide  surface,  is  not  elevated  above  the  level  of  the  black 
scab,  and  does  not  show  a  clear  line  of  demarcation  from  the  surround- 
ing normal  skin,  but  gradually  merges  into  it.  The  redness  which 
frequently  goes  with  this  process  has  caused  the  term  of  anthrax 


ANTHRAX 


39:> 


erysipelas  to  be  used  in  an  effort  at  characterization.  Pustules  which 
form  in  the  infected  zone  are  soon  covered  with  a  black  detritus,  and 
iarge  areas  of  skin  become  necrotic. 

In  both  forms,  the  lymph  channels  and  nodes  take  up  the  bacteria 
and  evince  their  invasion  by  swollen,  painful  cords  and  nodules  which 
are  readily  palpated.     Often  these  "watch  dogs"  of  the  general  cir- 


FiG.  146. — Anthrax  Carbuncle. 
(External  Anthrax)    (Symmers:  Bellevue  Hospital  case). 

culation  succeed  in  obviating  farther  aggression  on  the  part  of  the 
bacilli.  "When,  however,  the  excitants  succeed  in  breaking  through 
this  defense  in  virulent  form,  or  when  they  enter  the  circulation 
directly  through  a  fresh  wound,  thc}^  migrate  into  the  vascular  organs, 
such  as  the  spleen  and  the  liver,  where  they  multiply  with  great 
rapidity.  Although  the  presence  of  anthrax  bacilli  in  the  blood  is 
more  difficult  to  determine  than  obtains  in  connection  with  pyogenic 


396  INFECTIONS  OF  WOUNDS 

bacteria,  it  is  certain  that  they  are  disseminated  by  way  of  the  blood 
currentj  they  have  been  known  to  transmigrate  the  placenta  and 
enter  the  fetal  circulation. 

On  autopsy,  the  anthrax  bacilli  are  often  found  associated  with 
pyogenic  bacteria  of  various  kinds;  the  associated  bacteria  gain 
access  to  the  circulation  through  the  primary-  pustule. 

The  course  of  local  external  anthrax  is  accompanied  by  fever  in  only 
twenty-five  per  cent  of  the  cases  (K.  Mtiller^").  It  is,  at  times,  of  a 
high  degree,  but  disappears  promptly  (in  a  few  days)  when  the  local 
process  subsides.  In  severe  cases  of  general  infection,  with  diarrhea, 
delirium  and  restlessness,  it  remains  high  and  persists  until  death, 
which  ensues  in  about  seven  days.  When  mixed  infection  with  pyo- 
genic excitants  occurs,  the  lymph  channels  are  invaded  and  Ij^mphatic 
abscesses  develop ;  these  are  accompanied  by  a  renewal  of  fever. 

The  occurrence  of  anthrax  infection  without  a  local  lesion,  either 
upon  the  surface  of  the  body,  in  the  lung,  or  in  the  gut,  is  exceedingly 
unusual. 

The  diagnosis  of  external  anthrax  attended  with  characteristic 
appearances  should  not  be  difficult.  In  any  event,  microscopical  veri- 
fication must  not  be  omitted.  In  doubtful  cases,  culture  and  inocula- 
tion may  be  resorted  to.  However,  the  bacilli  can  be  found  during 
the  first  week  of  the  disease,  at  the  expiration  of  which  they  are 
destroyed,  partly  by  antagonistic  pyogenic  bacteria  and  partly  by  the 
action  of  bactericidal  substances.  Pyogenic  infections  to  which 
alcohol  has  been  applied  are  sometimes  covered  with  a  black  crust, 
giving  rise  to  a  pustule  resembling  anthrax. 

In  lung  anthrax  the  bacilli  may  be  found  in  the  sputum,  and,  when 
the  gut  is  the  seat  of  the  lesion,  they  may  be  found  in  the  feces. 

The  prognosis  depends  upon  the  seat  of  the  primary  carbuncle  or 
edema.  The  scalp,  face,  and  neck  are  unfavorable  locations,  as  the 
swelling  in  the  neck  may  give  rise  to  aspiration  pneumonitis,  and 
edema  glottidis.  Anthrax  of  the  upper  extremity  is  attended  with  a 
mortality  of  fourteen  per  cent,  that  of  the  legs,  five  per  cent.  The 
results  with  conservative  treatment  are  considerably  better  (see 
below) . 

Notwithstanding  the  fact  that  external  anthrax  in  man  is  rarely 
fatal,  and  most  often  remains  localized  as  the  result  of  the  activities 
of  the  bactericides,  the  possibility  of  the  stroDEN  absorption  of  viru- 
lent BACILLI  with  a  CONSEQUENT  FATAL  OUTCOME  MUST  NOT  BE  LOST 
SIGHT  OF. 


ANTHRAX  397 

In  the  treatment  of  external  anthrax,  measures  tending  to  promote 
absorption  of  the  excitant  must  be  carefully  avoided.  This  danger  is 
greatest  when  incision  and  curettage,  or  excision  of  the  carbuncle  or 
of  the  lymph  nodes,  is  practiced;  it  is  also  present  when  the  cautery 
is  used,  when  the  infected  tissue  is  injected  with  antiseptic  fluids,  or 
when  frequent  applications  of  hot  compresses  are  made. 

As  even  extensive  carbuncles  and  ediematous  infiltrations  subside 
spontaneously,  measures  of  the  sort  mentioned  are  not  only  useless, 
lilt  may  he  responsible  for  a  fatal  outcome.  It  is  certain,  that  in 
cases  in  which  general  infection  has  developed,  local  operative  attack 
cannot  serve  a  useful  purpose. 

Therefore,  the  conservative  treatment  advocated  by  v.  Bergmann^*, 
which  tends  to  avoid  the  employment  of  measures  that  lessen  the 
resistance  of  the  tissues  to  infection,  or  create  additional  opportunity 
for  the  entrance  of  virulent  bacteria,  may  be  regarded  as  particularly 
applicable  in  the  care  of  external  anthrax.  The  invaded  area  should 
l)e  protected  with  lint  thickly  covered  with  sterile  salve  to  prevent 
friction,  and  the  part  immobilized  b}^  means  of  carefully  applied 
apparatus,  and  suspended  in  an  elevated  position.  Thus  the  fever  is 
caused  to  subside  gradually  and  the  scab  is  spontaneously  exfoliated 
in  about  two  weeks. 

Removal  of  the  crust,  by  means  of  wipes  or  forceps,  is  an  erroneous 
procedure  which  is  often  avenged  by  the  development  of  lymphangitis 
and  lymphatic  abscesses  —  the  result  of  trauma  to  reparative  granu- 
lations —  which  become  ports  of  entrance  for  pyogenic  excitants.  The 
immohilizing  apparatus  is  left  in  situ  until  the  swelling  of  the  lymph 
nodes  has  entirely  suhsided,  nor  should  it  he  frequently  changed. 

Ahsccsses  caused  by  mixed  infections  should,  of  course,  be  incised 
and  drained.  Defects  of  lips,,  eyelid,  etc.,  following  necrosis  of  skin, 
may  be  repaired  by  plastic  methods. 

The  influence  that  rest  of  infected  tissues  has  upon  the  development 
of  systemic  invasion  is  shown  by  experiments  carried  out  on  mice 
(which  are  very  susceptible  to  the  disease) .  Friedrich^"'  immersed  the 
wounded  end  of  the  tail  of  a  mouse  in  a  bouillon  culture,  and  confined 
the  animal  in  this  position  for  several  hours ;  general  infection  did 
not  follow,  and  the  animal  survived  because  the  infected  wound  was 
not  subjected  to  mechanical  irritation.  When  a  few  drops  of  culture 
are  ruhhed  into  a  wound,  fatal  general  infection  immediately  follows. 

Prophylaxis,  as  regards  anthrax  in  the  human,  is  conserved  by 
various  means,  chief  of  which  is  the  avoidance  of  contact  ivith  infected 


398  INFECTIONS  OF  WOUNDS 

animals.  Infected  animals  should  be  killed  and  buried  deep  in  the 
ground  or  incinerated.  Stahles  should  be  frequently  cleansed  and 
disinfected.     Hides  should  be  exposed  to  live  steam. 

In  severe  cases  the  serum  treatment  should  be  employed  (p.  393). 

BIBLIOGRAPHY 

1.  PoLLENDER.     Quoted  by  Sobernheim,  No.  5. 

2.  Brauell.     Quoted  by  Sobernheim,  No.  5. 

3.  Devaine.     Comptes  rend  d  I'acad.  des  sci.  Ivii,  1863. 

4.  Koch.     Cohn's  Beitr.  z.  Biol.  d.  Pflanzen,  ii.  1876. 

5.  Sobernheim.     In  Kolle-Wassermann  Handb.  d.  Path.  Microorg.  Aufl.  ii, 

Bd.  3, 1913. 

6.  DiEUDONXE.     Arb.  a.  d.  kais.  Gesundbeitsamt.,  1894. 

7.  Emmerich.     Miincb.  rued.  Woch.,  1907. 

8.  Trincas.     Annali  d'Igiene  sperimentale,  N.  S.  29,  1909. 

9.  Preisz.     Zentrbl.  f.  Bakt.  Orig.  Bd.  58,  1911. 

10.  Sobernheim.     In  Kraus-Levaditi's  Handb.  d.  Immun.  Bd.  2,  1909. 

11.  ScLAvo  and  Mendez.     Zentrbl.  f.  Bakt.  xviii,  1895. 

12.  Koch.     Deutsch.  Chir.,  1886. 

13.  K.  MuLLER.     Deutsch.  med.  Woch.,  1894. 

34.     V.  Bergmann.     System  of  Surgery,  Trans,  by  Bull,  i,  1904. 
15.     Friedrich.     Arch.  f.  klin.  Chir.  Bd.  59,  1899. 


CHAPTER  XVIII 

GLANDEKS  —  MALLEUS 

Glanders  is  an  infectious  disease  due  to  a  specific  bacterium.  The 
disease  in  horses  was  described  by  Aristotle  and  Hippocrates  and  was 
recognized  in  the  human  by  Oslander  early  in  the  eighteenth  century. 
Human  pathogenicity  was,  however,  not  accepted  until  proved  by  the 
labors  of  EUiotson,  Gerlach,  Virchow  and  Bollinger^  (1876). 

The  glanders  bacillus  or  bacillus  mallei  (Fig.  147),  though  seen  and 
described  by  several  earlier  observers,  was  first  obtained  in  pure  cul- 
ture and  accurately  studied  by  Loffler  and  Schiitz^  in  1882.     Lofifler^ 

described  the  bacillus  as  a  slender 
small  rod  with  rounded  ends. 
The  length  varies  from  three  to 
five  microns,  its  breadth  from  0.5 
to  0.75  micron.  It  varies  con- 
siderably in  the  same  culture. 
The  bacillus  is  non-motile,  has  no 
flagella,  and  does  not  form  spores. 
While  the  glanders  bacillus 
stains  readil}'  with  the  usual 
anilin  dyes,  it  is  easily  discolored. 
Stained  in  the  usual  manner  with 
methylene  blue,  it  shows  consid- 
FiG.  147.—  Glanders  Bacilli  in  Tissue,  erable  irregularity  in  its  staining 

qualities,  a  characteristic  re- 
garded as  of  diagnostic  significance.  It  is  decolorized  by  Gram's 
method  of  staining.  For  the  purpose  of  staining  the  haciUus  in  tissue, 
the  method  of  Klihne*  is  found  most  useful,  or  sections  may  be  stained 
in  alkaline  methylene  blue  solution  or  in  borax  methylene  blue,  after 
which  decolorization  may  be  achieved  in  Loffler 's  mixture  (Aq.  dist. 
10  c.cm.,  concentrated  sulphuric  acid  gtt.  ii,  and  5  per  cent  oxalic  acid 
solution  gtt.  i). 
Cultivation  of  glanders  bacilli  is  best  accomplished  on  ghjcerin  agar 

399 


400  INFECTIONS  OF  WOUNDS 

and  on  Mood  serum;  on  gelatin,  growth  is  very  slow.  Their  virulence 
subsides  rapidly  when  cultured,  but  they  may  be  reactivated  by  inocu- 
lation into  animals,  of  which  guinea  pigs  are  the  most  susceptible. 
After  subcutaneous  inoculation,  the  animals  die  in  a  few  weeks.  The 
site  of  the  injection  develops  circumscribed  purulent  inflammation, 
from  which  the  process  extends  to  the  contiguous  lymph  channels,  and 
gradually  invades  the  entire  body  in  the  form  of  metastatic  foci. 
Nodes  appear  in  the  lungs,  the  spleen,  and  the  scrotum.  The  joints 
develop  pyo-arthroses,  and  foci  appear  in  the  mucosa  of  the  nose. 

Glanders  toxin  is  not  formed  by  the  livmg  bacilli,  but  is  given  up 
upon  their  death,  and  therefore  is  an  endotoxin. 

The  disease  is  transmitted  to  man  (who  is  not  particularly  sus- 
ceptible), in  most  instances,  by  means  of  the  nasal  and  buccal 
MUCUS,  OR  THE  PUSS  FROM  INFECTED  ANIMALS.  In  horses,  donkcys, 
mules,  and  asses  the  disease  is  endemic,  and  usually  primarily  invades 
the  mucosa  of  the  nose,  where  it  causes  diffuse  or  nodular  infiltration, 
which  later  ulcerates,  so  that  the  copious  secretions  are  just  as  infec- 
tious as  is  the  pus -of  a  broken  down  skin  lesion.  For  this  reason, 
aside  from  the  laboratory  infections,  persons  concerned  in  the-  care  of 
animals  are  most  commonly  affected. 

The  jiorts  of  entrance  of  the  infection  are  often  small  ivounds  of  the 
skin  of  the  face  and  hands,  though  it  has  been  experimentall}-  shown 
that  the  bacilli  may  (like  staphylococci)  be  rubbed  into  the  hair  bulbs 
of  the  normal  skin,  with  a  resultant  local  pathogenesis  and  a  general 
infection.  At  times,  though  not  often,  the  infection  attacks  the  con- 
junctiva, the  lips,  and  the  nose  at  its  nostrils,  i.  e.,  where  rhagades  or 
slight  injuries  are  common.  The  excitants  have  been  transmitted  dur- 
ing coitus,  causing  glanders  of  the  genitals  (Strube-^).  In  the  mucous 
membranes,  the  disease  forms  small  nodules  (rich  in  cells)  which  soon 
ulcerate  and  invade  the  respiratory  passages.  In  the  skin,  the  pro- 
cess, in  its  acute  phase,  takes  on  the  form  of  a  cutaneous  or  subcuta- 
neous inflammation  attended  with  the  formation  of  nodules  not  unlike 
earbunculosis,  which  soon  break  out  as  glanders  pustules,  or  undergo 
gangrenous  disintegration,  extend  b}^  phagedenic  ulceration  and 
exhibit  undermined  edges  with  sloughing  bases.  When  the  granulo- 
matous nodules  spread  in  the  .subcutaneous  tissues,  their  extension  is 
accompanied  by  the  formation  of  abscesses  which  discharge  a  thin, 
stinking  pus. 

These  changes  are  attended  with  fever  and  the  other  constitutional 
symptoms  of  an  acute  infectious  disease,  and  in  a  short  time  the  con- 


GLAXDEKS  401 

tiguous  lymph  channels  are  invaded.  The  lymph  nodes  become  swollen 
end  painful  {glanders  huho),  and  small  nodules  appear  in  the  course 
of  the  lymphatics  which  form  abscesses  that  soon  ulcerate.  .  However, 
the  bacilli  are  disseminated  mainly  by  the  blood  (from  which  they  may 
be  isolated  during  life),  thus  giving  rise  to  multiple  metastases  in  the 
form  of  inflammatorj^  nodules,  areas  of  nodular  infiltration,  and  pyo- 
genic foci.  These  foci  are  embolic  in  origin,  the  fibrinous  flocculi 
being  derived  from  the  thrombosed  veins  which,  at  the  site  of  the 
primary  lesion,  are  thickly  infested  with  glanders  bacilli.  The  embolic 
carriers  find  residence  in  the  holies  and  in  the  joints  {osteomyelitis 
malleosa  of  Virchow^),  causing  purulent  inflammation,  or  they  pro- 
voke multiple  abscesses  in  the  subcutaneous  tissues  and  muscles,  or 
gain  access  to  the  vital  organs,  especially  the  lungs,  where  they  induce 
the  formation  of  small  celled  nodules  w^hich  break  down  and  give  rise 
to  the  picture  of  a  severe  bronchitis  or  pneumonitis.  By  the  same 
hematogenous  route,  the  bacilli  themselves  invade  the  skin  and  cause 
the  formation  of  skiii  pustules  (not  unlike  pemphigus  or  variola),  and 
of  ulcers  in  the  mucosa  of  the  air  passages  —  the  nose,  the  mouth,  the 
pharjTix,  and  the  larynx.  When  the  subcutaneous  tissue  is  invaded, 
the  overlying  skin  takes  on  a  bright  hue  resembling  erysipelas,  but 
does    not    spread.     Very    severe    constitutional    symptoms  —  fever, 

DELIRIUM,  COMA,  VOMITING,  AND  DIARRHEA ATTEND  THIS  ACUTE  FORM 

OF  THE  DISEASE  UNTIL  DEATH,  WHICH,  UNFORTUNATELY,  ALMOST  ALWAYS 
SUPERVENES  IN  TWO  OR  THREE  WEEKS,  AS  THE  RESULT  OF  EITHER  GENERAL 
BACTERIAL  INFECTION  OR  EXHAUSTION. 

The  subacute  and  the  chronic  forms  of  the  disease  may  persist  for 
months  and  years ;  of  these,  about  fifty  per  cent  recover  unless  sud- 
denly terminated  by  an  acute  exacerbation  of  the  disease.  In  these 
forms,  the  local  process  proceeds  very  slowly,  leaving  extensive  defects 
in  its  W'ake.  The  skin  infiltrate  takes  on  the  form  of  large  worm  or 
wreath  shaped  nodules  (therefore,  the  name  of  "worm"  has  been 
applied  to  the  chronic  cutaneous  form  of  the  disease)  which  ultimately 
ulcerate  and  coalesce  into  extensive  areas  of  tissue  destruction.  "When 
the  ulcers  have  sharply  defined  borders  and  cicatricial  repair  occurs 
on  one  side,  they  take  on  a  peculiar  ''kidney  shaped"  outline  resem- 
bling syphilitic  lesions,  especially  when  the  process  is  located  near  the 
lips,  in  the  gums,  or  at  the  nostril,  and  exude  a  thin,  fetid  secre- 
tion. The  chronic  form  of  glanders  is  also  accompanied  by  the  forma- 
tion of  metastatic  foci,  though  these  are  usually  insular  and  develop 
at  long  intervals. 


402  INFECTIONS  OF  WOUNDS 

The  diagnosis  of  glanders  is  not  difficult  in  its  chronic  form ;  in  the 
acute,  confusion  arises, —  especially  at  the  beginning  —  when  a  pri- 
mary lesion  is  absent,  in  connection  with  typhus  fever,  acute  articular 
rheumatism,  and  other  pyogenic  general  infections.  In  order  to  dif- 
ferentiate the  chronic  cutaneous  form  from  syphilis,  it  may  be  neces- 
sary to  administer  mercury  and  the  iodids,  though,  of  course,  the 
result  in  connection  with  the  "Wassermann  test  is  also  helpful.  Acti- 
nomycosis and  tuberculosis  are  also  to  be  taken  into  account.  The 
resemblance  of  chronic  glanders  to  lupus  is  illustrated  by  the  fact  that 
some  of  the  older  writers  used  the  term  lupus  malleus  when  describing 
this  form  of  the  disease. 

For  diagnostic  purposes,  the  bacteriological  test  of  Strauss''  may  be 
made.  This  consists  of  intraperitoneal  inoculation  of  guinea  pigs  with 
glanders  pus,  whereupon,  in  from  two  to  three  days,  the  scrotum 
swells  and  the  tunica  vaginalis  is  infiltrated  with  purulent  exudate, 
unless  the  animal  dies  of  pyogenic  general  infection  accidentally  intro- 
duced at  the  same  sitting.  Of  course,  the  presence  of  glanders  bacilli 
must  be  determined  by  microscopical  examination  before  the  inocula- 
tion is  made.  It  is  doubtful  whether  the  injection  of  the  sterile 
culture  extract,  mallein  (Preusse^),  is  as  useful  a  diagnostic  measure 
in  man  as  it  is  when  injected  into  horses.  Bonome"  reports  producing 
febrile  reaction  in  a  case  of  chronic  glanders  by  the  subcutaneous 
injection  of  mallein.  Zieler^°  made  similar  injections  in  two  cases, 
neither  of  which  showed  either  local  or  systemic  reactions.  It  would 
seem  as  though  better  results  may  be  attained  by  the  serodiagnostic 
method  of  Schiitze  and  Schubert  (complement  fixation  test),  reported 
by  Meisner  and  Trapp." 

The  treatment  of  virulent  acute  glanders  is  unsatisfactory.  When 
general  infection  is  established,  neither  conservative  nor  radical  local 
measures  are  of  value.  If  the  surgeon  were  certain  that  systemic 
invasion  were  imminent,  amputation  might  avail.  In  the  milder 
forms,  excision  of  the  port  of  entrance  together  with  removal  of  the 
contiguous  lymph  nodes  may  arrest  the  progress  of  the  disease.  When 
this  is  done,  unnecessary  trauma  must  he  avoided;  only  very  sharp 
cutting  instruments  should  be  used  and  the  curette  and  strong  anti- 
septic solutions  banished.  The  general  resistance  of  the  patient 
should  be  maintained  and  efforts  made  to  alleviate  suffering. 

In  the  chronic  forms  of  the  disease,  the  injection  of  killed  glanders 
bacilli  (Zieler^^)  would  seem  to  be  justified. 

Prophylaxis  depends  upon  flf^sures  addressed  to  the  destruction  of 


GLANDERS  403 

infected  animals  which  would,  of  course,  obviate  the  occurrence  of  the 
disease  in  the  human. 

BIBLIOGRAPHY 

1.  BoLLiXGER.     Handb.  d.  si^ec.  Path.,  Leipzig,  1876. 

2.  LoFFLER  and  Sciiultz.     Deutsch.  med.  Woch.,  1882, 

3.  LoFFLER.     Arb.  a.  d.  kais.  Gesundheitsamt.,  1886. 

4.  KuHXE.     Fortschr.  d.  Med.,  1886. 

5.  Strl-be.     Arch.  f.  klin.  Chir.  Bd.  61,  1900. 

6.  ViRCHOw.     Die  Krankhaften  Geschwuelste,  Bd.  2. 

7.  Strauss.     Arch,  de  med.  exper.,  1889. 

8.  Preusse.     Berlin  tierarzt.  Woch.,  1898. 

9.  BoxoME.     La  Reforma  med.,  1894. 

10.  ZiELER.     Zeitschr.  f.  Hvff.,  Bd.  45,  1903. 

11.  Meisxer  and  Trapp.     Zentrbl.  f.  Bakt.  Orig.,  Bd.  52,  1909. 

12.  Zieler.    Med.  klin.,  1909,  No.  18. 


CHAPTER  XIX 

ACTIXOMYCOSIS 

Actinomycosis  is  an  infectious  disease  endemic  in  animals,  occurs  in  man,  is 
due  to  the  "  ray  fungus,"  appears  in  the  form  of  a  local  and  general  infection, 
and  is  usually  insidious  in  character.  Its  progress  is  attended  ivith  the  pro- 
liferation of  granulation  tissue^  ivhich  appears  in  the  form  of  nodules  or  in 
the  guise  of  tissue  destruction  and  abscess  formation,  and  is  distinguished  by 
the  p)resence  of  characteristic  actinomycosis  kernels,  composed  of  the  yellowish 
residue  of  degenerated  fungi. 

The  excitant  of  actinomycosis  is  a  trichomycete,  a  higher  order  of 
bacterium  discovered  by  Bollinger^  in  1877,  found  in  the  human  by 
James  Israel^  in  1878  and  obtained  in  pure  culture  by  Oskar  IsraeP 
in  1884. 

The  parasites  appear  in  the  infected  tissues  and  in  the  purulent 
exudate  in  the  form  of  granules  plainly  visible  to  the  naked  eye,  of  a 
pale  grayish,  yellow  color,  and  resemble  sulphur  granules.  The}"  are 
about  the  size  of  a  grain  of  sand  or  the  head  of  a  pin.  The  kernels 
consist  of  one  or  more  colonies.  According  to  Bostrom*  a  single 
granule  consists  of  an  outer  layer  of  cluh  shaped  radiations  the  central 
ends  of  which  are  tapered  and  merge  into  a  slender  thread-like  central 
mass  (mycelium).  The  central  portion  of  the  granule  ma}'  be  divided 
into  two  layers :  A  peripheral,  very  dense  mass  of  filaments  with 
bushy  radiations  {spore  zone)  ;  and  a  less  dense  center  from  which  a 
portion  breaks  through  the  outer  layers  of  club  shaped  bodies  {root), 
and  invades  the  surrounding  tissue. 

The  individual  filaments  are  about  the  thickness  of  an  anthrax 
bacillus  and  give  off  irregularly  undulating  branches.  These  filaments 
separate  into  rods  and  coccus-like  portions  which,  according  to 
Bostrom,'*  are  the  spores  of  the  parasite.  This  is  disputed  by 
Hiss  and  Zinsser;"'  however,  Bostrom*  holds  that  an  entire  new 
granule  may  be  evolved  from  either  a  single  filament  of  the  spore  zone 
or  from  the  spores,  but  not  from  the  "clubs,"  and  that  the  disease  is 
spread  by  the  two  former  elements.  Swelling  of  an  end  of  a  filament 
is  the  beginning  of  club  formation.  These  clubs  are  structureless, 
though  they  refract  light,  form  the  ray  wreath,  and  are  the  result  of 

404 


ACTINOMYCOSIS 


405 


hyalin  degeneration  of  the  sheath  of  the  filaments.  In  the  smaller  and 
younger  granules  they  are  very  fragile  and  soluble  in  water ;  in  older 
lesions  they  develop  into  a  thick  layer,  and  at  times  become  calcified. 
Cultivation  of  the  ray  fungus  may  be  easy  or  difficult,  according  to 
whether  the  specimen  is  contaminated  or  not.  The  granules  are  care- 
fully crushed  between  cover  glasses,  or  mixed  in  bouillon  in  a  mortar, 
and  will  grow  on.  any  of  the  laboratory  media.  After  a  few  days,  at 
a  temperature  of  37.5°C.  (99.5°F.),  the  cultures  appear  in  the  form 
of  translucent  specks,  which  in  two  weeks  become  small,  yellowish 


Fig.  148. —  Actixomycosis  Kernel, 
A,  Section  through  a  fully  developed  colony  (after  Bostrom).    a,  Point  at  which 
central  filamentous  mass  breaks  through  the  external  layer  of  clubs;   &,  germinal 
layer  surrounded  by  clubs.     B,  Section  through  a  degenerated  colony   (Bostrom). 

kernels.  The  culturing  does  not  cloud  bouillon.  Some  strains  of  the 
fungus  grow  best  under  aerobic  conditions  (Bostrom^),  others  where 
anaerobiosis  is  maintained  (J.  Israel  and  Wolf ^) .  An  anaerobic  strain 
was  obtained  by  Harbitz  and  Grondahl'  from  an  actinomycotic  focus 
in  the  human. 

The  fungus  stains  with  the  aniline  dyes  and  is  Gram  positive. 
Double  staining  is  accomplished  with  gentian  violet  (for  the  filaments) 
and  picrocarmin  (for  the  ''clubs").  Sections  may  be  stained  b^-  the 
Gram  method  combined  with  carmin,  or  the  "clubs"  may  be  colored 
with  eosin  and  the  tissues  with  hematoxylin. 

Successful  animal  inoculation  is  not  easy.     J.  Israel  and  M.  Wolf^ 


406  INFECTIONS  OF  WOUNDS 

succeeded  in  producing  tumors  containing  fungi  by  inoculating  cul- 
tures into  the  peritoneum  of  rabbits  and  guinea  pigs. 

The  cultural  differences  in  the  fungi  derived  from  the  human  by 
Israel  and  Wolf^  and  those  described  by  Bostroni*  would  seem  to 
indicate  that  there  are  different  kinds  of  organisyns  helonging  to  the 
actinomycosis  family  which  are  capable  of  producing  closely  allied 
clinical  pictures  (Silberschmidt*).  Lachner-SandovaP  considers  the 
ra}^  fungus  and  its  related  fungi  as  belonging  to  the  provisional  class 
of  hyphomycetes.  Petruschky^^  places  the  actinom^'ces,  streptothrix, 
cladothrix,  and  leptothrix  among  the  species  of  the  hair  fungi  family, 
or  trichomycetes  —  a  group  of  h^^phomycetes. 

Actinom^'ces  fungi  are  found  attached  to  the  stems  of  grain  and 
straw,  in  the  air  canals  of  which  ihey  rapidly  multiply.  Particles  of 
grain  stems  thus  fertilized  have  been  found  in  lesions  in  cattle  and  in 
the  human.  Brestnew,"  after  prolonged  effort,  was  able  to  demon- 
strate their  presence  on  dried  plauts,  hay,  straw,  etc. ;  and  Liebmann^^ 
showed  that  after  infecting  earth  with  fungus  cultures,  portions  of 
the  crop  —  beans,  rye,  and  barley  —  were  the  seat  of  ray  fungus 
growth.  In  dried  grain  stems,  the  parasite  remains  viable  for  more 
than  a  year  (SchlegeP^). 

In  animals  and  in  man  (in  whom  the  disease  is  rare),  the  infection 
is  usually  conveyed  by  means  of  portions  of  grain,  though  the  parasite 
may  enter  the  body  of  the  host  through  injuries  of  the  skin,  and,  in 
some  instances,  attack  the  mucosa  of  the  mouth,  the  pharynx,  the 
esophagus,  and  the  gut  of  persons  who  habitually  chew  whisps  of  hay 
or  straw.  They  are  also  at  times  introduced  together  with  foreign 
bodies  such  as  splinters  of  wood. 

Extension  of  the  infection  by  contiguity  is  assumed  from  the  fact 
that  the  fungi  primarily  invade  carious  teeth,  and  secondarily  involve 
the  jaw  and  the  cheek.  According  to  the  investigations  of  Partsch^* 
who  found  actinomycosis  granules  in  the  cavities  of  teeth  and  attached 
to  their  roots,  there  would  seem  to  be  no  doubt  in  this  connection.  In 
other  instances,  actinomycosis  has  been  found  associated  with  fracture 
of  the  lower  jaw  and  in  the  alveolar  processes  following  the  extraction 
of  a  tooth,  which  would  argue  for  secondary  invasion  on  the  part  of 
the  parasite  into  the  wound  or  into  inflamed  areas,  after  they  had,  no 
doubt,  for  a  considerable  period  of  time,  led  a  saprophytic  existence 
in  the  mouth. 

In  the  tissues,  the  ray  fungus  usually  provokes  a  chronic 
progressive  inflammation,  creating  a  wide  zone  of  cellular  infil- 


ACTINOMYCOSIS  407 

TRATE,  CONSISTING  OF  GRANULATIONS  AND  OF  CONNECTIVE  TISSUE,  WHICH 
SURROUNDS  ITS  COLONIES  AND  EXTENDS  WITH  IT  OVER  WIDE  AREAS.    While 

in  man  the  infection  is  not  often  attended  with  the  domination  of 
tumor  formation  as  obtains  in  cattle  (in  which  the  growths  were 
believed  to  be  sarcomatous),  nevertheless,  even  in  the  human  the 
pathogenesis  of  the  process  is  that  of  a  proliferation  of  cellular  ele- 
ments, rather  than  one  of  exudation  and  tissue  degeneration,  as  is  the 
rule  with  other  inflammatory  processes.  The  inflammatory  new 
growth  is  "board  like"  in  character,  extends  gradually  into  the  sur- 
rounding tissue,  merges  with  the  skin,  and  is  intimately  associated  with 
the  deeper  parts.  In  its  deeper  portions,  the  infiltrate  undergoes 
fatty  degeneration  and  forms  small  insular  areas  of  softening,  while 
the  overlying  skin  takes  on  a  deep  blue  black  color  which  gradually 
thins  in  spots  that  finally  ulcerate,  and  give  egress  to  a  moderate 
amount  of  thin  fluid  richly  endowed  with  kernels  (fungus  colonies) 
and  masses  of  disintegrated  granulation  tissue.  The  broken  down 
superficial  areas  are  followed  by  the  formation  of  persistent  fistulous 
tracts  by  means  of  which  communication  with  the  deep  areas  of  disin- 
tegration is  maintained.  Uncomplicated  ray  fungus  infection  is  not 
attended  with  phlegmonous  inflammation  and  acute  symptoms,  such 
as  fever,  etc.;  when  this  occurs,  it  is  due  to  co-incident  pyogenic 
invasion. 

Extensive  involvement  is  attended  with  a  depression  of  the  general 
condition  of  the  patient,  which  takes  on  the  form  of  a  cachexia,  and  is 
soon  followed  by  a  fatal  outcome. 

Actinomycosis  (as  far  as  is  known)  does  not  invade  the  lymph 
vessels  nor  the  lymph  nodes.  It  is,  however,  disseminated  by  the 
blood  current  when  the  fungi  gain  access  to  veins  in  the  infected  zone 
(actinomycotic  thrombophlebitis).  As  is  common  in  all  infected  pro- 
cesses that  spread  by  entholisni,  the  excitants  may  be  deposited  in  any 
of  the  parts,  organs,  and  tissues  of  the  body.  "Wrede^^  reports  a  case 
of  hematogenous  osteomyelitis  of  the  trochanter  of  the  femur.  The 
clinical  picture  of  general  actinomycosis  is  similar  to  that  of  a  chronic 
metastatic  pyogenic  infection  and  is  always  fatal. 

Actinomycosis  is  classified,  in  accord  with  its  port,  of  entrance,  into 
actinomycosis  of  the  oral  cavity,  of  the  lung,  of  the  intestinal  tract, 
and  of  the  skin. 

To  the  first  group  belong  the  infections  of  the  face  and  neck. 
Actinomycosis  of  the  face  or  cheek  originates  in  the  buccal  mucosa,  or 
in  the  alveolar  processes  of  the  jaws.     In  the  latter,  the  process  begins 


408  INFECTIONS  OF  WOUNDS 

as  a  small  infiltrate  in  the  gum.  When  the  cheek  is  involved,  ' '  lock 
jaw,"  due  to  infiltration  of  the  muscles  of  mastication,  begins  early. 
Infectious  beginning  in  the  center  of  the  cheek  near  the  opening  of 
Stenson's  duct,  in  front  of  the  masseter  muscle,' are  usually  not  at 
once  complicated  by  rigidity  of  these  muscles  (Schlange^'').  At  times, 
a  hard,  indurated  cord,  corresponding  to  the  course  of  the  disease, 
may  be  felt  extending  from  an  alveolar  process  or  from  a  carious  tooth 
to  the  cheek.  From  the  cheek,  the  hard  infiltrate  extends  deeply  in  all 
directions,  attaches  itself  to  the  bone  and  invades  the  suhmaxillary  and 
temporal  regions.  The  latter  is  also  invaded,  by  extension,  on  the 
inner  side  of  the  cheek  following  along  the  ascending  ramus  of  the 
lower  jaw.  From  the  superior  maxilla,  actinomycosis  invades  the 
orbital  and  nasal  cavities,  or  extends  along  the  l}ase  of  the  skull  into 
the  cranial  cavity,  where  it  gives  rise  to  fatal  meningitis  and  encepha- 
litis. When  the  process  involves  hone,  it  usually  takes  on  the  form 
of  a  periostitis.  This  is  observed  in  connection  with  the  vertehral 
column,  to  the  anterior  surface  of  which,  the  inflammation,  at  times, 
extends  from  the  pharynx,  and  by  proceeding  along  the  vertebral 
bodies,  gains  access  to  the  abdominal  cavity;  on  the  other  hand, 
extension  from  an  alveolar  focus  to  the  central  portion  of  the  lower 
jaw  is  rare. 

The  neck  is  invaded  by  gravitation  from  the  lower  jaw,  or  from  the 
phqrrjnx  by  way  of  the  tonsil  and  retropharyngeal  tissue ;  occasionally, 
the  mucosa  of  the  esophagus  and  of  the  larynx  are  ports  of  entrance 
for  the  infection.  In  the  neck,  the  process  is  attended  by  the  appear- 
ance of  transverse,  bluish  red,  indurated  folds  of  skin,  the  seat  of 
numerous  subcutaneous  abscesses  that  break  down  and  are  followed 
by  the  formation  of  persistent  fistulae  through  which  the  character- 
istic ray  fungi  are  discharged.  When  gigantic  infiltration  of  the  neck 
occurs,  movements  of  the  head  are  restricted,  deglutition  is  painful, 
and  respiration  is  embarrassed. 

The  tongue  is  not  often  attacked,  but  when  it  is,  the  process  is  likely 
to  be  mistaken  for  lues.  When  the  infiltrate  breaks  down  it  resembles 
pyogenic  infection,  and  when  the  lips  and  floor  of  the  mouth  are 
indurated,  carcinoma  is  simulated. 

Primary  aspiration  actinomycosis  of  the  lung  (for  which,  according 
to  Israel,''  the  deposit  of  an  infected  splinter  from  a  tooth  may  be 
responsible)  may  appear  in  any  portion  of  the  lung,  but  attacks  most 
frequently  the  lower  portion.  At  times,  the  process  is  limited  to  a 
superficial,  catarrhal  inflammation  of  the  air  passages,  but  usually 


ACTINOMYCOSIS  *  409 

appears  as  bronchopneumonic  foci  which  undergo  central  d'mntegra- 
iion  a7id  are  surrounded  hy  connective  tissue  induration  that  shows  a 
tendency  to  contract.  Lung  actinomycosis  at  first  resembles  tuber- 
culous phthisis;  it  has,  however,  a  singular  tendency  not  to  restrict 
itself  to  the  lung,  hut  to  extend  into  the  surrounding  parts,  while  the 
disintegrated  portion  of  the  lung  undergoes  contractile  shrinkage. 
Extension  to  the  pleura  takes  on  the  form  of  serous  pleuritis,  or  its 
two  layers  coalesce  followed  by  transmigration  of  the  thoracic  walls ; 
in  this  way,  numerous  fi-stulae  develop  or  tumor  like,  hard  nodules 
appear  upon  the  ribs  or  in  the  skin.  The  pericardium  is  invaded 
through  the  mediastinum,  or  the  process  extends  along  the  vertebrae, 
breaks  through  the  diaphragm,  reaching  the  pelvis,  or  creeps  into  the 
peritoneum  where  it  gives  rise  to  peritonitis,  and  gains  access  to  the 
liver  and  spleen.  Secondary  invasion  of  the  lung  occurs  hy  extension 
of  actinomycosis  from  the  abdominal  cavity,  or  is  metastatic  in  origin, 
which  latter  is  likely  to  follow  the  lodgment  of  an  infected  embolus 
in  a  branch  of  the  pulmonarj^  vein.  In  all  forms  of  actinom^^cosis  of 
the  lung,  the  fungi  should  be  present  in  the  sputum,  though  failure  to 
demonstrate  their  presence  is  not  diagnostically  conclusive. 

Intestinal  actinomycosis  begins  most  often  in  the  cecum  and  in  the 
contiguous  portions  of  the  ileum  and  colon,  while  other  parts  of  the 
gastro-intcstinal  tract  are  rarely  primarily  attacked.  The  early  stages 
of  actinomycosis  of  the  gut  are  usually  chronic,  and  create  little  or  no 
disturbance;  at  times,  however,  it  is  attended  with  pain,  fever,  and 
rigidity  in  the  ileocecal  region,  closely  resembling  acute  perityphlitis 
or  appendicitis.  The  process  in  the  gut  is  primaril}'  restricted  to  the 
raucous  membrane,  but  soon  extends  to  the  other  layers,  involving  the 
peritoneum  where  an  adhesive  peritonitis  is  developed.  This  granulo- 
matous inflammation  of  the  peritoneum  leads  to  the  formation  of  large, 
hard,  tumor-like  enlargements,  easily  palpated  through  the  abdominal 
wall;  these  areas  soon  break  down  into  abscesses  whose  contents  are 
replete  with  colonies  of  the  causative  parasites  by  means  of  which  the 
process  is  disseminated  in  all  directions,  invading  other  portions  of  the 
gut,  the  rectum,  the  bladder,  and  the  overlying  skin,  the  last  being 
frequently  the  seat  of  fistulae,  especially  in  the  navel,  the  right  lumbar, 
and  the  gluteal  regions,  to  which  the  infection  extends  by  way  of  the 
retroperitoneal  tissues.  Fecal  fistulae  occur  when  communication  with 
the  gut  and  with  the  skin  is  established.  In  cases  in  which  the  intra- 
abdominal lesion  is  deeply  located  or  has  undergone  connective  tissue 
isolation,  secondary  infiltration  of  the  skin  may  occur  and  the  primary 


410  INFECTIONS  OF  WOUNDS 

focus  may  escape  detection.  Dissemination  of  the  infection  through 
the  portal  circulation,  and  invasion  of  the  liver,  follows  actinomj^cosis 
of  the  intestines  in  the  same  way  as  obtains  with  metastatic  processes 
generally.  Although  primary  infection  of  the  intestinal  mucosa 
extends  by  contiguity  to  the  abdominal  contents  and  its  walls,  these 
may  also  be  invaded  by  metastatic  einholi  originating  in  a  primary 
focus  located  elsewhere  in  the  body. 

Actinomycosis  of  the  skin,  though  usually  secondary  to  infection 
elsewhere,  does  nevertheless  occur  primarilij  when  foreign  'bodies, 
e-specially  fertilized  stems  of  grain,  penetrate  it.  In  this  location  the 
process  appears  as  lupus-like  nodules  or  nodular  infiltration,  abscesses, 
'ulcers,  and  fistulas,  in  accord  with  the  duration  of  the  disease.  Deeply 
extending  infiltrates  which  gradually  reach  the  bone  and  enmantle  it 
present  the  picture  of  a  suppurative  osteomyelitis. 

The  diagnosis  of  actinomycosis  is  an  involved  problem,  especially  in 
the  stages  preceding  softening  and  the  expulsion  of  disintegrated  tis- 
sues and  fluid  contents.  Bacterioscopic  identification  of  the  fungi  is, 
of  course,  conclusive ;  however,  the  examination  must  be  made 
promptly  as  the  "clubs"  disappear  soon  (one  day) after  the  discharge 
of  the  parasite  from  the  lesion.  The  kernels  themselves  are  not 
always  present  in  the  secretion  and  are  difficult  to  find  in  tissue.  The 
chronic  course  of  an  actinomycotic  induration  may,  at  any  time,  be 
disturbed  by  the  invasion  of  a  mixed  infection,  causing  the  develop- 
ment of  an  acute  suppurative  phlegmon  and  abscess  formation,  and 
thus  the  true  character  of  the  process  is  not  revealed  until  the  incision 
is  made,  or  until  nodules  and  fistulae  make  their  belated  appearance. 

When  the  formation  of  inflammatory  new  growths  is  the  dominant 
factor  in  the  picture,  the  process  is  easily  confused  wdth  sarcoma, 
gummatous  infiltration,  and  the  deposit  of  new  bone  occurring  in  con- 
nection with  pyogenic  infections.  In  the  cheek,  examination  of  the 
mucous  membrane  and  the  discovery  of  a  hard,  indurated  cord  leading 
from  an  alveolar  process  is  helpful  in  arriving  at  a  tentative  con- 
clusion. The  recognition  of  the  ray  fungi  in  the  sputum  and  in  the 
feces  discharged  from  fistulae  is  of  course  of  great  diagnostic 
assistance. 

The  prognosis  varies  wath  the  form  the  disease  takes.  A  significant 
fact  is  the  observation  of  Schlange,^*'  who  states  that,  ivhen  the  infiltra- 
iion  is  not  too  deeply  located,  spontaneous  repair  follows  discharge  of 
the  fungi  bearing  granulations.  For  this  reason,  actinomycosis  of  the 
head  and  face  usually  runs  a  favorable  course,  while  that  of  the  lungs 


ACTINOMYCOSIS  411 

and  gut  is  frequently  fatal.  Invasion  of  the  cranial  cavity  is  always 
fatal.  Extension  of  the  process  to  vital  organs,  its  wanderings  along 
the  vertebral  column,  and  the  invasion  of  the  blood  current  are  all 
attended  with  an  unfavorable  outlook. 

The  treatment  is  directed  toward  supporting  nature  in  its  efforts  at 
encapsulation  and  expulsion  of  the  fungus  colonies.  Instead  of  com- 
plete excision  of  the  entire  granulomatous  mass,  it  is  only  necessary  to 
follow  the  course  of  the  fistulous  tracts,  expose  hy  incision  the  small 
granulating,  suppurating  foci  within  the  infiltrate  and  remove  them 
with  a  spoon.  How^ever,  this  procedure  does  not  usually  succeed  at  one 
sitting,  and  may  have  to  be  repeated  several  times.  The  wound  is  left 
open  and  lightly  packed  with  iodoform  gauze.  Repair  usually  is  not 
accomplished  until  after  the  lapse  of  weeks  and  montlis.  The  admin- 
istration of  large  doses  of  iodin  is  believed  to  have  a  distinct  therapeutic 
effect.  Recovery  is  possible  when  the  process  in  the  lung  and  in  the 
gut  is  not  too  extensive  and  egress  is  given  to  the  parasites  by  the 
formation  of  fistulae  (Schlange,^"  Karewski,^^  Lexor^^),  and  when  the 
infection  is  exposed  by  resection  of  ribs,  or  otherwise,  and  treated  in 
the  manner  stated. 

In  inaccessible  foci,  the  fistulae  must  be  protected  against  intercur- 
rent contamination,  and  consequent  secondary  infection.  The  nutri- 
tion of  the  unfortunate  host  must  of  course  receive  attention.  When 
joints  are  invaded,  resection  may  be  resorted  to.  Amputation  is 
rarely  necessary. 

BIBLIOGRAPHY 

1.  Bollinger.     Deutsch.  Zeitschr.  f.  Thiermed,  iii,  1887. 

2.  James  Israel.     Vireh.  Arch.  No.  74,  1878,  and  No.  78,  1879. 

3.  OsKAR  Israel.     Virch.  Arch.  Bd.  95,  1884. 

4.  BosTROM.     Beitr.  z.  path.  Anat.  Bd.  9,  1890. 

5.  Hiss  and  Zinsser.     Textbook  of  Bact.,  N.  Y.,  1916. 

6.  J.  Israel  and  Wolf.     Vireh.  Arch.  Bd.  126,  1891,  Bd.  151,  1898. 

7.  Harbitz  and  Grondahl.     Beitr.  z.  path.  Anat.  Bd.  50,  1911. 

8.  Silberschmidt.     Zeitschr.  f.  Hyg.  u.  Inf.  Bd.  37,  1901. 

9.  Laciiner- Sandoval.     Strassburg,  Beust,  1898,  with  lit. 

10.  Petruschky.     Handb.  d.  path.  Mikroorg.  von  Kolle-Wassermann,  Aufl. 

2,  Bd.  5,  1912. 

11.  Brestnew.     Same  as  No.  10. 

12.  LiEBMANN.     Same  as  No.  10. 

13.  ScHLEGEL.     Same  as  No.  10. 

14.  Partsch.     Same  as  No.  10. 

15.  Wrede.     Chir.  Kon^.  Verh.  ii,  1906. 

16.  SCHLANGE.     Arch.  f.  klin.  Chir.  Bd.  44,  1892. 

17.  Karewskl     Verh.  d.  Berlin  med.  Gesel.  ii,  1898. 

18.  Lexer.     Zentrbl.  f.  Chir.,  1910. 


CHAPTER  XX 
MADUEA    FOOT 

The  term  madura  foot  is  applied  to  a  chronic  progressive  inflamma- 
tory process  which  presents  a  picture  peculiar  to  itself,  attacks  the 
feet  (at  times,  though  rarely,  the  hands),  and  was  first  observed  in 
Madura  (India)  in  1712,  and  later  in  America  and  Africa  (Babes^. 

The  disease  begins  {usually)  with  a  painless  swelling  of  the  sole  of 
one  foot.  Very  slowly,  round,  bluish  red,  soft  nodes  are  formed,  which 
gradually  merge  into  one  another.  These  nodes  break  and  form 
fistulous  tracts  which  heal  and  break  out  again.  Gradually,  the 
inflammatory  process  extends  to  the  back  of  the  foot  and  invades 
the  tendons,  the  joints,  the  periosteum,  and  the  bones.  The  last  dis- 
integrate or  become  cystic.  The  fistulae  discharge  a  thin,  foul  smell- 
ing pus,  which,  like  that  of  actinomycosis,  contains  small  yellow  or 
black  kernels.  Madura  fungi  is  classified  according  to  the  color  of 
these  kernels. 

The  madura  fungus,  which  may  be  cultivated  on  defibrinated  coagu- 
lated blood  of  horses,  belongs  to  the  streptothrix  group.  The  kernels 
consist  of  thickly  interlaced  filaments  which  are  arranged  in  a  radial 
fashion  at  the  periphery.  The  absence  of  "clubs"  differentiates  them 
from  the  ray  fungus  (Koch  and  Stutzer^). 

The  pathogenesis  provoked  by  the  fungus  is  similar  to  the  granu- 
lomatous and  nodular  formations  of  actinomycosis. 

Amputation  ends  the  process.  "When  this  is  not  done,  death  follows 
after  years  of  slow  progression  of  the-  local  process  and  exhaustion. 
Early  incision  and  curettage  may  eradicate  the  disease. 

BIBLIOGRAPHY 

1.  Babes.     In  Kolle-Wassermann  Handb.  d.  path.  Microorg.  Ed,  ii,  Bd.  5, 

1911. 

2.  Koch  and  Stutzer.     Zeitsclir.  f.  Hyg.  u.  Inf.,  Bd.  69,  1911. 


412 


CHAPTER  XXI 
BLASTOMYCOSIS 

Blastomycosis  or  saccharoniycosis  in  man  is  rare  and  has  only  re- 
cently been  studied.  It  is  believed  to  be  due  to  an  infection  with  an 
organism  of  the  yeast  fungus  class.  Cutaneous  blastomycosis  was 
observed  by  Gilchrist^  in  1884  and  Busse-  reported  a  case  in  1895;  it 
would  seem,  however,  that  Gilchrist  did  not  report  his  case  until  after 
Busse 's  was  published.  Gilchrist  founded  his  assumptions,  at  that 
time,  on  the  microscopical  findings  and  considered  the  excitants  to  be 
protozoa,  later,  he  also  obtained  the  fungus  in  pure  culture.  The 
p.rst  recorded  case  of  general  infection  was  that  of  Busse^  (1894), 
and  the  second  that  of  Montgomery.^  Blastomycetes  were  demon- 
strated in  the  sputum  by  Eisendrath  and  Ormsby*  (1905),  and  in 
fecal  matter  in  the  same  case,  reported  by  LeCount  and  Meyer. ^  Since 
then  a  number  of  cases  have  been  observed. 

The  hiological  position  of  the  causative  organism  seems  to  be  still 
a  matter  of  doubt.  In  tissue,  its  method  of  reproduction  is  by  germi- 
nation. It  is  made  up  of  a  capsule  (oceasionalh^,  an  additional  adven- 
titious capsule),  a  clear  zone,  granules,  and,  at  times,  a  vacuole.  Its 
size  varies  from  5  to  15  microns,  but  may  be  as  large  as  30  microns. 
The  organism  is  oval  or  round,  surrounded  by  a  homogeneous,  doubly 
contoured,  refractible  capsule,  immediately  within  which  is  a  clear 
zone,  while  the  center  contains  granules  of  various  sizes  and  shapes  and, 
sometimes,  a  vacuole.  The  protoplasmic  granules  are,  at  times,  baso- 
philic which  is  demonstrated  by  means  of  Unna's  polychrome  methy- 
lene hlue  stain. 

Endogenous  spore  formation  is  not  proved;  however,  the  capsule 
often  ruptures  and  liberates  small  granules,  similar  to  those  within 
the  cell  body,  which  may  be  concerned  in  reproduction. 

The  organism  is  easily  identified  in  fresh  pus  or  in  tissue  mounted 
in  a  ten  per  cent  solution  of  potassium  hydrate  and  may  be  easily 
stained  with  any  of  the  aniline  dyes. 

The  cultural  characteristics  of  blastomyces  present  multiform 
appearances  depending  upon  the  media  used,  and  the  temperature  at 

413 


414 


INFECTIONS  OF  WOUNDS 


which  it  is  grown.  It  grows  well  on  glycerin,  glucose,  agar,  blood 
serum,  and  in  broth;  as  a  rule,  satisfactory  cultural  flora  is  obtained 
at  room  temperature,  the  growth  beginning  to  appear  in  from  two 
to  fourteen  days.  In  the  incubator,  growth  is  somewhat  more  luxur- 
ious and  rapid.    It  may  be  said  that  the  organisms  develop  in  tissue 


Fig.  149. —  Micropiiotograph,  Cutaneous  Section  (High  Power)  Showing 
Giant  Cell  Containing  Organisms  op  Blastomycosis.  (Courtesy  of  the 
Journal  of  the  American  Medical  Association.) 

by  budding  only;  on  media  by  segmental  mycelial  formation  with 
lateral  conidia,  and  later,  by  a  certain  number  of  budding  forms. 

Inoculation  produces  general  infection  in  mice  and  guinea  pigs. 
The  latter  are  more  resistant,  but  the  administration  of  large  doses 
is  followed  by  general  infection  and  the  appearance  of  the  fungi  in 
practically  all  of  the  organs.  Greatest  pathogenesis  seems  to  be  pro- 
duced in  animals  at  the  end  of  the  third  week  after  inoculation. 

The  cutaneous  lesions  vary  from  a  small  beginning  papulopustule  to 
larg''e  patches  several  inches  in  diameter.  A  patch  about  the  size  of  a 
twenty-five  cent  piece  presents  the  following  characteristics: 


BLASTO:\n'COSIS  415 

It  is  surrounded  hu  a  Muish  red  areola  which  is  studded  with  small 
miliary  abscesses  characteristic  of  the  disease.  The  areola  gradually 
slopes  from  the  elevated  path  to  the  normal  surrounding  skin  and  is 
about  one  fourth  of  an  inch  m  width.  The  main  part  of  the  lesion  is 
elevated  to  about  one  eighth  of  an  inch,  has  a  flat  top  and  is  papillo- 
matous or  verrucous,  is  crust  colored,  and  either  discharges  pus  or  is 
superficiall}'  ulcerated.  By  pressure,  pus  can  be  made  to  exude  from 
between  the  papillomatous  projections.  The  miliarj'  abscesses  in  the 
aerola  are  characteristic,  and  vary  from  minute,  barely  visible  points, 
to  lesions  the  size  of  a  pinhead.  These  lesions  discharge  a  glaring, 
mucopurulent  secretion  from  which  the  causative  excitants  ma}'  be 
obtained  in  pure  culture.  Portions  of  the  patch  undergo  involution 
and  scar  tissue  is  formed. 

The  course  of  the  disease,  in  its  cutaneous  form,  is,  as  a  rule,  chronic, 
though  intermittent  periods  of  acute  exacerbation  occur.  The  patches 
may  be  closely  apposed  or  widely  separated;  for  instance,  a  patch 
ma}^  appear  on  the  face  and  another  on  an  extremity ;  when  healing 
seems  to  be  complete  the  fungus  is  often  still  present,  and  may 
provoke  renewed  pathogenesis. 

The  clinical  picture  of  a  general  hlastomycotic  infection  is  that  of 
a  chronic  inflammatory  process,  and,  like  actinomycosis,  resembles 
chronic  metastatic  pyogenic  infection.  This  form  of  blastomycosis 
differs  from  actinomj'cosis  only  with  respect  to  the  causative  factor 
(see  Actinomycosis,  p.  404),  and,  indeed,  even  in  this  regard,  the 
difference  is  not  great. 

The  similarity  blastomycosis  hears  to  actinomycosis  is  applicable  to 
its  pathology,  diagnosis,  and  treatment.  It  may,  however,  be  proper 
to  add,  that  the  probable  differexces  in  the  biological  character- 
istics OF  THE  excitant  MAY,  IN  THE  FUTURE,  HAVE  AN  IMPORTANT 
BEARING  IN  CONNECTION  W^TH  VACCINE  OR  SEKUM  THERAPY. 


BIBLIOGRAPHY 

1.  Gilchrist.    Johns  Hopkins  Hosp.  R.  i,  1896. 

2.  BrssE.     Zentrbl.  f.  Bakt.,  etc.,  1894,  xvi. 

3.  Montgomery.     Jr.  A.  M.  A.,  xxxviii,  Xo.  33. 

4.  EiSEXDRATH  aud  Ormsby.     Jr.  A.  M.  A.,  Oct.,  1905. 

5.  LeCouxt  aud  Meyer.     Jr.  Inf.  Dis.,  1907,  iv. 


CHAPTER  XXII 
SPOEOTEICHOSIS 

Sporotrichosis  is  an  infectious  disease,  which,  because  of  its  resem- 
blance to  tuberculosis,  lues,  and  chronic  pyogenic  infections,  was  not 
identified  as  a  distinct  process  until  deBeurmann  and  Gougerot^ 
(1903)  discovered  its  causative  excitants. 

The  sporotrichum  Beurmanni  is  a  parasite  closely  resembling  the 
blastomyces  and  was  first  described  in  this  country  by  Schenck,^ 
Sporotrices  belong  to  the  so-called  fungi  imperfecti,  and  occur  in 
lesions  as  oval  or  cigar  shaped  spores  (conidia)  ;  they  grow  in  culture 
as  branching  septate  mj'celia  with  clusters  of  oval  or  spherical  con- 
idia about  the  ends  of  the  hj^phae.  According  to  some  observers,  the 
conidia  are  attached  to  the  mycelium  by  short  pedicles.  The  conidia 
are  also  attached  along  the  sides  of  the  hyphae  and  are  often  grouped 
in  whorls  about  the  threads.  Chlamydospores  are  also  found  in  some 
cultures.  The  organisms  are  obligatory  aerobes,  and  grow  on  all 
ordinary  culture  media.  The  cultural  flora  forms  a  thick,  leathery, 
white  coating  on  the  surface  of  the  medium  which,  as  the  cultures 
age,  becomes  brown  and  sometimes  black.  The  parasite  stains  best  by 
Gram's  method  which  makes  its  recognition  difficult  in  exudate.  The 
serum  of  infected  persons  causes  agglutination  of  the  spores,  a  charac- 
teristic of  considerable  serodiagnostic  value. 

Of  the  animals,  dogs,  cats,  and  especially  rats,  are  susceptible. 

The  disease  is  uncommon,  yoi  has  been  thoroughly  studied  by 
Bloch,^  Dind,*  Gougerot,^  Hamburger,"  de  Lapersonne,''  Moure  et 
Baufle,«  and  Olson.'' 

The  course  and  the  clinical  picture  of  sporotrichosis  are  exceedingly 
variable.  Acute  and  chronic  lesions  coexist  and  consist  of  irregularly 
distributed  painless  nodes  situated  in  •  the  skin  and  subcutaneous 
tissues.  These  nodules  are  at  first  covered  by  areas  of  inflammation, 
and  in  a  few  weeks  increase  in  size,  take  on  the  characteristics  of 
gummata  and  break  down  into  abscesses  which  discharge  thick, 
tenacious,  threadlike  pus;  this  is  followed  by  persistent  ulcers  with 

416 


SPOROTRICHOSIS  417 

indurated  edges.  This,  so-called,  syphiloid  form  of  the  disease  differs 
from  the  tuhercidaid  which  remains  nodular.  At  times,  the  infection 
lakes  on  a  papillary  form  not  unlike  skin  tuberculosis. 

In  both  forms,  the  lytiiph  channels  and  the  lymph  nodes  are  invaded, 
in  contradistinction  to  actinomycosis  and  blastomycosis  which  spread 
by  means  of  the  blood  current.  The  general  condition  of  the  host  is 
rarely  disturbed,  a  peculiarity  of  many  infectious  processes  when  the 
lymphatics  have  an  opportunity  to  exercise  their  bactericidal  capacity. 

On  the  other  hand,  there  is  a  third  form — coccidial — which  gains 
access  to  the  blood  current,  and  is  characterized  by  general  distur- 
bances and  high  fever.  This  form,  like  acute  general  pyogenic  infec- 
tions, follows  a  severe  course,  is  attended  with  the  formation  of  mul- 
tiple abscesses,  and  terminates  fatally  in  a  short  time. 

For  the  purpose  of  treatment  of  sporotrichosis,  the  administration 
of  large  doses  of  iodid  is  almost  specific.  The  local  lesio)is  are  treated 
along  the  lines  of  general  surgical  principles. 

BIBLIOGRAPHY 

1.  DE  Beurmaxx  et  Gougerot.     Felix  Alcan,  Paris,  1912. 

2.  ScHExXCK.     Johns  Hopkins  Hosp.  Bull.,  1898,  286. 

3.  Block.     Med.  Klinik.,  1909,  with  lit. 

4.  DiXD.     Deutsch.  Zeitsehr.  f.  Chir.  Bd.  116.  1912. 

5.  Gougerot.     In  KolIe-AYassermann  Handb.  d.  path.  Microorg.   Aufl.  2, 

Bd.  5,  1912. 

6.  Hamburger.     Jr.  A.  M.  A.,  lix,  1912. 

7.  DE  Lapersoxxe.     La  Presse  med.,  1912. 

8.  Moure  et  Baufle.     Same  as  No.  7. 

9.  Olson.     Same  as  No.  6. 


CHAPTER  XXIII 

TUBEECULOSIS 

General  Considerations. — Altliougli  the  infectious  nature  of  tubercu- 
losis was  accepted  as  clinically  demonstrated  for  a  long  time,  and 
Klencke^  in  1843,  transmitted  the  disease  by  inoculation  of  tuberculous 
"material,"  and  Villamirr  presented  convincing  evidence  in  this  con- 
nection in  1865,  it  was  not  until  1882  that  Koch^  succeeded  in  isolating 
and  cultivating  the  Uibercle  hacillus.  Baumgarten*  had  previously 
seen  the  bacillus  in  tissue  sections  but  his  researches  were  limited  to 
morphological  observations.  Koch,  in  addition  to  demonstrating  the 
bacillus  in  tuberculosis  tissues  from  various  sources,  produced  char- 
acteristic lesions  in  guinea  pigs  and  other  animals  by  inoculation  with 
pure  cultures,  and  established,  beyond  doubt,  the  etiological  relation- 
ship of  the  bacillus  to  the  disease. 

Koch's  discovery  made  it  possible  to  recognize  the  multitudinous 
pathological  manifestations  of  tuberculous  infection  of  the  various 
parts,  organs,  and  tissues  of  the  body  as  dependent  upon  a  single  prO' 
vocative  excitant. 

There  has  been,  despite  strong  evidence  to  the  contrary,  a  doubt, 
as  to  the  transference  of  tuberculosis  from  animals  to  man ;  this  doubt 
was  based  on  the  findings  of  Koch^  who  was  unable  to  communicate 
the  disease  by  inoculating  cattle  and  pigs  with  bacilli  from  the  human ; 
however,  there  is,  at  this  writing,  no  douht  that  the  infection  is  com- 
municated from  the  lower  animals  to  mail.  Recent  investigations, 
especially  those  of  Kossel,*^  Heuss  and  Weber,'^  have  shown  that  cer- 
tain morphological  and  cultural  differences  exist  between  bacilli 
obtained  from  lesions  in  the  human  (typus  humanus)  and  those  found 
in  cattle  (typus  hovinus),  though  these  are  very  slight.  It  has  also 
been  shown  that  there  is  a  difference  in  the  character  of  pathological 
processes  produced  by  the  two  types  of  bacilli.  When  introduced 
into  mammals,  the  typus  bovinus  evinces  greater  virulence  than  does 
the  typus  humanus.  Cattle  display  little  susceptibility  to  the  latter, 
while  pigs  and  goats,  when  inoculated  subcutaneously,  develop  a  low 

418 


TUBERCULOSIS  419 

grade  of  slowly  extending  tuberculosis.  Rabbits  are  also  not  par- 
ticularly susceptible  to  the  typus  humanus,  while  guinea  pigs  do  not 
seem  to  show  any  difference  in  this  regard  with  either  type  of  bacilli. 
Anthropoid  types  of  monkeys,  inoculated  and  fed  with  both  types  of 
bacilli,  shoM^ed  no  differences  in  susceptibility'  (v.  Dungern^).  Ebers," 
by  transmitting  the  typus  humanus  to  cattle,  and  by  repeated  inocu- 
lation, was  able  to  produce  an  exceedingly  virulent  strain  of  typus 
bovinus — thus  converting  one  into  the  other.  The  reverse  has  also 
been  accomplished  in  culture. 

The  important  practical  question — whether  the  differences  between 
bovine  tubercle  bacilli  and  human  tubercle  bacilli  make  precautions 
against  transmission  of  the  disease  in  this  connection  unnecessary, 
must  be  answered  in  the  negative.    While  it  is  true,  that  tuberculosis 

IN  MAN  IS  USUALLY  THE  RESULT  OF  INFECTION  WITH  THE  TYPUS  HU- 
MANUS,   IT    MAY    ALSO    BE    THE    OUTCOME    OF    INVASION    BY    THE    TYPUS 

BOVINUS.  The  latter  may  be  the  causative  excitant  in  children,  especi- 
ally those  fed  with  cow's  milk,  not  alone  in  primary  intestinal  and 
mesenteric  gland  tuberculosis,  but  in  tuberculosis  of  the  peritoneum, 
vital  organs,  and  spleen ;  in  miliary  tuberculosis  and  in  a  certain  num- 
ber of  tuberculous  cervical  glands;  in  lesions  of  joints  and  in  the 
skin;  it  ma}-  also  attack  wounds  (Burkhardt"),  and  has  been  found 
responsible  for  lesions  involving  mucous  membrane  (A.  Weber'^). 
In  the  Cornet  and  KosseP^  analysis,  the  typus  bovinus  was  the  pro- 
vocative excitant  as  follows : 

General  tuberculosis,  23.8  per  cent ;  in  tuberculosis  cervical  adenitis 
in  children,  40  per  cent ;  in  tuberculosis  of  abdominal  organs  in  chil- 
dren, 13.6  per  cent,  in  adults,  49  per  cent.  This  would  seem  to  show 
conclusively  that  the  typus  hovinus  tubercle  hacillus  may  provoke  all 
the  various  forms  of  tuhcrculosis  in  the  human  hcing. 

The  bacillus  of  chicken  tuherculosis  (typus  gallinaceus)  is  probably 
not  capable  of  producing  tuberculosis  in  man. 

The  Bacillus  Tuberculosis. —  Tubercle  bacilli  (Fig.  150)  are  slender 
rods  2-4  microns  in  length  and  0.2-0.5  microns  in  width;  they  have 
slightly  rounded  ends,  are  usually  straight,  but  may  be  somewhat 
curved.  Their  diameters  are  not  always  uniform,  giving  them,  when 
stained,  an  irregular  appearance  which  is  attributed  to  various  rea- 
sons. Unstained  spaces  along  the  body  of  the  bacillus — especially  in 
old  cultures^ — are  generally  regarded  as  vacuoles;  on  the  other  hand, 
the  bodies  of  the  bacilli  may  bulge  at  several  places,  in  the  form  of 
oval  or  rounded  knobs,  which  stain  deeply  and  are  very  resistant  to 


420  INFECTIONS  OF  WOUNDS 

decolorization.  These  protuberances  were,  at  one  time,  believed  to  be 
spores,  but  this  view  has  been  dismissed  on  the  ground  that  the  bacilli 
are  no  more  resistant  to  heat  than  other  vegetative  forms.  The  bacilli 
are  believed  to  possess  a  cell  membrane  which  enhances  their  resis- 
tance to  drying  and  interferes  with  the  entrance  of  stains.  This 
membrane  gives  a  cellulose  reaction  and  is  thought  to  be  the  source 
of  the  waxy  substance  that  can  be  extracted  from  the  cultures. 

Branched  forms  of  the  tuhercJr  hacillus  have  been  demonstrated  by 
Klein,^^  Nocard  and  Roux,^*  and  others.  These  observations,  variously 
extended  and  elaborated,  make  it  probable  that  the  haciUus  tubercu- 
losis is  not  a  member  of  the  family  of  schizomycetes  but  belongs  rather 
to  the  higher  bacteria,  hciiig  closely  re- 
lated to  the  actinomijces  (Hiss  and 
Zinsser^^). 

Stai)n)ig  of  tubercle  bacilli  is  not 
easily  accomplished  with  the  ordinary 
aniline  dyes,  to  which  they  are  made 
permeable  only  by  long  exj^osure  or  by 
heating  of  the  staining  solution.  Once 
stained,  however,  the  dye  is  tenaciously 
retained  despite  treatment  with  alcohol 
and  strong  acids.  For  this  reason 
the    bacillus    is    spoken    of    as    "acid 

„       ^    ,,         „,  -T      n       ^  ^  £     XI         ^IG-      ISO. TUEERCLE     BaCILLI     IN 

last.         the    acid   fast   nature    or   the  Fresh  Sputum. 

bacillus  seems  to  be  due  to  the  fatty 

substances  contained  within  it  (Bienstock^*^).  Thus,  all  the 
staining  methods  depend  upon  the  use  of  an  intensely  pene- 
trating staining  solution  follow^ed  by  "\agorous  decolorization 
which  deprives  all  but  the  acid  fast  group  of  their  color. 
Counter  stains  of  any  of  the  weaker  dyes  may  then  be  used  to 
STAIN  THE  DECOLORIZED  ELEMENTS.  The  dye  most  commonly  used  is 
ZiehlV^  carbol  fuchsin  solution  (fuchsin,  1  gm.  in  10  c.cm.  absolute 
alcohol,  added  to  90  c.cm.  of  5  per  cent  carbolic).  Thin  smears  on 
slides  or  cover  slips  are  deluged  with  the  d^^e  and  gently  heated.  The 
dye  is  allowed  to  act  for  about  three  minutes  (steaming  —  not  boiling)  ; 
at  the  end  of  this  time,  the  preparation  is  washed  with  5  per  cent  nitric 
acid  or  20  per  cent  sulphuric  acid  or  1  per  cent  hydrochloric  acid 
until  most  of  the  red  color  has  disappeared  (a  few  seconds)  and  only 
a  pale  pink  color  is  retained.  This  results  in  decolorization  of  all  the 
microorganisms  with  the  exception  of  those  of  the  acid  fast  group. 


TUBERCULOSIS  421 

The  specimen  is  now  thoroughly  washed  in  80  to  95  per  cent  alcohol 
10  complete  the  decolorization,  rinsed  in  distilled  water  and  counter 
stained  with  1  per  cent  aqueous  methylene  blue  solution,  after  which 
it  is  mounted  for  microscopic  examination. 

For  sputum,  pus,  urine,  feces,  etc.,  the  Ulilenhuth^®  ''antiformin" 
method  described  by  Rosenau^**  is  very  efficacious.  It  consists  of  using 
a  solution  composed  of  equal  parts  of  liquor  chlorinatus  and  a  15  per 
cent  solution  of  caustic  soda.  If  the  specimen  is  immersed  in  a  10 
to  15  per  cent  solution  of  antiformin  and  allowed  to  stand  for  several 
hours,  most  of  its  elements,  including  cells  and  other  bacteria,  will 
dissolve  out,  leaving  acid  fast  bacilli  in  the  residue.  The  process  does 
not  kill  the  acid  fast  bacilli,  and  if  sufficiently  washed  may  be  used 
for  the  purpose  of  inciting  tuberculosis  in  susceptible  animals  (guinea 
pigs) . 

For  sections,  Erlich's""  mixture  (11  c.cm.  saturated  alcoholic  gentian 
violet  to  89  c.cm.  of  5  per  cent  aniline  water)  or  Ziehl's^"  solution  may 
be  used.  The  specimen  is  left  in  contact  with  the  stain  for  from  twelve 
to  twenty-four  hours,  washed,  decolorized,  immersed  in  60  per  cent 
alcohol,  washed  again,  and  counter  stained  with  methylene  blue  or 
Bismarck  brown. 

For  the  differentiation  of  tubercle  hacilli  from  the  excitants  of 
leprosy  see  p.  478.  Smegma  'bacilli  also  must  be  taken  into  account. 
For  the  purpose,  aside  from  the  inoculation  test  which  is  the  most 
certain  one,  various  methods  of  staining  have  been  employed.  Of 
these,  the  one  of  Pappenheim'^  is  perhaps  as  valuable  as  any;  it  is 
based  on  the  fact  that  a  combination  of  alcohol  and  rosolic  acid  decolor- 
izes the  smegma  bacillus  and  leaves  the  excitant  of  tuberculosis  stained 
bright  red. 

The  isolation  and  cultivation  of  tubercle  bacilli  is  difficult.  Their 
slowness  of  growth  precludes  isolation  b.y  plating.  The  first  isolation 
was  accomplished  by  Koch^  who  employed  coagulated  blood  serum  for 
the  purpose. 

Isolation  of  the  bacilli  from  tuberculous  material  may  be  aided  by 
inoculation  into  guinea  pigs.  These  animals  withstand  the  acute 
infection  produced  by  contaminating  organisms  and  succumb  later 
(from  four  to  five  weeks)  to  tuberculosis.  The  bacilli  may  then  be 
obtained  from  cultivations  from  foci  which  follow  the  inoculation. 
When  isolation  from  sputum  is  attempted,  the  specimen  may  be 
rendered  comparatively  free  from  contaminating  bacteria  by  washing. 


422  INFECTIONS  OP  WOUNDS 

The  material  selected  for  examination  is  then  taken  from  the  center 
of  the  specimen. 

For  the  isolation  of  tubercle  bacilli  from  sputum  and  other  material 
in  which  contaminating  bacteria  are  present,  Petroff"^  has  devised  an 
excellent  method,  a  complete  description  of  which  may  be  found  in 
Petroff 's  original  article  (see  reference  No.  22)  or  in  Hiss  and  Zinsser 
(see  reference  No.  15). 

On  blood  serum,  at  37.5°C.  (99.5°F.)  colonies  become  visible  at  the 
end  of  eight  to  fourteen  days,  appearing  as  small,  dry,  scaly  spots 
with  corrugated  surfaces.  After  three  or  four  weeks,  these  coalesce, 
covering  the  surface  as  a  dry,  wrinkled,  whitish  deposit.  Theobald 
Smith^^  considers  coagulated  dog  serum  a  particularly  favorable 
medium  for  the  growth  of  the  tubercle  bacilli. 

Slants  of  agar  to  which  whole  rahlit's  blood  has  been  added  in 
quantities  of  from  1  to  2  c.cm.  to  each  tube,  make  an  excellent  medium. 

Glycerin  bouillon,  glycerin  potato,  and  glycerin  agar,  at  37.5° C. 
(99.5°F.)  are  all  favorable  culture  media  for  the  bacillus. 

The  artificial  production  of  tuberculosis  is  best  accomplished  by 
inoculating  guinea  pigs;  they  are  very  susceptible  to  the  disease 
and  die  in  from  ten  to  twenty  days  after  a  moderate-sized  portion  of 
tuberculosis  tissue  or  a  pure  culture  is  introduced  into  the  peritoneal 
sac;  they  also  succumb  in  a  few  weeks  when  the  inoculation  is  made 
subcutaneously.  In  the  latter  instance  small  nodules  or  ulcers  de- 
velop at  the  site  of  the  puncture;  these  are  soon  followed  by  general 
infection.  Systemic  tuberculosis  in  rabbits  occurs  only  after  intraven- 
ous or  intraperitoneal  inoculation.  Tuberculosis  may  be  artificially 
produced  by  feeding  with  cultures,  which  is  followed  by  invasion  of 
the  tonsil,  the  cervical  Ij^mph  nodes,  the  gut,  and  the  mesenteric  glands. 
The  inhalation  of  dried  cultures  has  been  followed  by  pulmonary 
tuberculosis,  and  their  injection  into  the  arterial  system  (femoral 
artery,  etc.)  has  provoked  lesions  in  bones  and  joints  (Friedmann^*). 

The  great  resistayice  of  tubercle  bacilli  explains  their  wide  patho- 
genicity, despite  the  fact  that  they  do  not  multiply  outside  the  animal 
body.  Neither  cold  nor  dryness  affect  their  viability.  They  readily 
survive  dry  heat  of  100°C.  (212°F.),  and,  in  the  sputum,  resist  the 
action  of  chemicals  for  a  long  time.  The  latter  characteristic  is 
ascribed  to  the  enmantling  capsule  they  possess.  On  the  other  hand, 
moist  temperature  of  95 °C.  (203 °F.)  kills  them  in  sputum  in  five 
minutes.    Thej^  are  killed  by  direct  sunlight  in  a  few  hours. 

The  variations  in  virulence  of  tubercle  bacilli  of  different  origin 


TUBERCULOSIS  423 

and  under  varying  cultural  conditions  (especially  reduction  of  viru- 
lence by  culture  and  reactivation  by  animal  inoculation)  is  dependent 
upon  tlieir  toxins  (v.  Bebring-"). 

Tbe  toxins,  according  to  v.  Bebring,  are  partly  contained  in  tbe 
culture  medium  and  in  part  in  tbe  bacilli;  tbose  contained  in  tbe 
bodies  of  the  bacteria  (wben  dead  bacilli  are  inoculated)  produce 
inflammation  and  suppuration,  and  wben  introduced  intravenously, 
in  tbe  form  of  an  emulsion,  provoke  tuberculous  tissue  hyperplasia 
(Kocb,  Masur  and  Kocbel,-®  and  otbers). 

Tbe  bacterial  residue  obtained  after  filtration  of  cultures  contains 
several  poisonous  substances.  By  chloroform  and  ether  extraction, 
Auclair-"  obtained  a  substance  corresponding  to  the  cheesy  material 
present  in  tuberculous  lesions.  Koch-^  obtained  his  tuberculin  by 
extraction  with  glycerin.  V.  Bebring,-^  by  various  manipulations 
separated  the  residue  into  several  substances  from  which  he  obtained 
the  end  product  tuberculin. 

The  immunization  of  animals  against  tuberculosis  and  their  cure  of 
the  disease  by  means  of  tuberculin  was  first  attempted  by  Koch."^ 
Guinea  pigs  treated  in  this  way  lived  longer  than  did  the  control 
animals  inoculated  at  the  same  time,  but  healing  was  not  accom- 
plished. In  practice  tuberculin  did  yiot,  at  first,  prove  of  value, 
because  it  was  used  in  doses  that  provoked  high  fever  and  a  severe 
reaction  in  the  inflamed  area.  This  local  and  systemic  reaction  when 
used  for  diagnostic  purposes  (especially  in  cattle),  is  of  great  assist- 
ance; however,  the  destruction  it  provokes  in  newly  formed  repair 
tissue  in  tuberculosis  foci  leads  to  a  dangerous  exacerbation  of  the 
infectioii.  It  is  true  that  tolerance  for  the  treatment  may  be  estab- 
lished (by  immunization)  so  that  the  reaction  no  longer  occurs;  how- 
ever, in  this  event,  the  extension  and  dissemination  of  the  disease  is 
not  hindered  because  the  immunization  does  not  have  any  direct  effect 
upon  the  bacilli. 

The  employment  of  the,  so-called,  "oZcZ  tuberculin"  as  a  thera- 
peutic measure,  should,  according  to  Sahli,-'*  aim  to  prevent  general 
or  local  reactions.  For  the  purpose,  subcutaneous  injections  of  .05  to 
0.1  mg.  are  made  twice  weekly  and  gradually  increased  to  0.1  gm.  The 
dose  is  reduced  to  the  initial  quantity  as  soon  as  the  temperature  rises. 

"With  tbe  view  of  immunizing  against  the  bacilli  themselves,  and 
to  rob  the  method  of  its  objectionable  features,  Kocb^°  devised  a  num- 
ber of  methods.  The  culmination  of  these  efforts  may,  according  to 
Ruppel,^^  be  stated  as  follows : 


424  INFECTIONS  OF  WOUNDS 

Virulent  cultures  of  tubercle  bacilli  are  dried  in  vacuo  and  thor^ 
oughly  ground  in  a  mortar  until  no  intact  bacilli  are  revealed  in  stained 
samples.  One  gram  of  the  dried  mass  is  shaken  up  in  100  c.cm.  of 
sterile  distilled  water  and  the  mixture  centrifuged  at  high  speed.  The 
supernatant  fluid  known  as  TO  (tuberculin  oherschicht)  contains  the 
constituents  of  the  bacilli  that  are  soluble  in  water,  does  not  preci- 
pitate on  the  addition  of  50  per  cent  glycerin,  and  has  the  same  physi- 
ological action  as  the  ''old  tuberculin."  The  residue,  TR  {tul}erculin 
rilclistand),  after  decanting  TO,  is  again  shaken  in  water  and  centri- 
fugalized.  This  process  is  repeated  several  times  and  eventually — 
after  three  or  four  repetitions — all  the  TR  goes  into  emulsion.  The 
total  amount  of  water  used  for  these  TR  extractions  should  not  exceed 
100  c.cm.  All  the  TR  emulsions  are  then  mixed  together.  This  gives 
TR  a  precipitate  with  50  per  cent  glycerin,  and  is  believed  by  Koch 
to  contain  substances  of  value  in  the  production  of  an  antibacterial 
immunity. 

Despite  the  good  results  obtained  in  immunizing  animals,  this  pre- 
paration, called  new  tuberculin,  did  not  produce  the  desired  effect 
when  used  by  clinicians.  Other  tuberculins  are  those  of  Beraneck^^ 
— highly  recommended  by  Sahli  f^  that  of  Klebs  f^  and  that  produced 
from  bovine  tubercle  bacilli  by  Spengler.^^  The  latest  preparation  is 
that  obtained  by  culturing  tubercle  bacilli  in  association  with  a  tricho- 
phyton fungus  which  is  supposed  to  lessen  the  toxic  effects  of  the 
former  without  lessening  its  immunizing  power  (Rosenbach^^). 

The  immunization  of  cattle  was  first  attempted  by  v.  Behring^'^ 
(1902)  by  the  inoculation  of  bacilli  of  human  origin.  As  the  typus 
humanus  is  less  virulent  for  cattle  than  is  the  bovinus,  v.  Behring, 
basing  his  notion  on  Jenner's  protective  inoculation  in  connection  with 
smallpox,  conceived  the  idea  that  he  could  protect  cattle  against  bovine 
tuberculosis  by  immunizing  them  with  the  typus  humanus,  hence  the 
term  jenerization.  The  vaccine  ibovovaccine)  is  prepared  in  accord 
with  a  certain  formula  (see  bibliography,  references  Nos.  37  and  38). 
V.  Behring 's  observations  have  been  verified  by  Baumgarten,^^  but, 
according  to  Ebers,"  the  increases  resistance  (against  artificial  infec- 
tion) is  of  short  duration,  so  that  vaccinated  animals  may  not  (safely) ' 
be  regarded  as  immune  against  tuberculosis  (stable  infection). 

For  the  purpose  of  diagnosticating  tuberculosis  in  man,  the  old 
tuberculin  of  Koch-*  {alftuberkidin)  is  usually  employed.  The  subcu- 
taneous injection  of  1  mg.  of  this  preparation  into  tuberculous  per- 
sons is  followed  within  twenty-four  hours  by  a  rise  of  temperature ;  if 


TUBERCULOSIS  425 

this  does  not  occur  within  a  few  days  5  mg.  are  injected.  The  disadvan- 
tage of  the  method  lies  in  the  possibility  of  exacerbation,  if  not  ac- 
centuation of  the  process  (Baumg-trten,^'  Sahli^^).  For  this  reason, 
the  less  harmful  method  of  cutaneous  vaccination  of  v.  Pirquet,^®  which 
is  not  followed  by  a  sj'stemic  reaction,  is  largely  employed.  The  skin 
is  scratched  with  a  small  sharp  lancet  and  the  tuberculin  applied  to 
the  traumatized  area ;  in  twentj'-f our  hours  a  round  inflammatory 
infiltrate,  surmounted  by  a  serous  bleb,  appears ;  this  recedes  in 
from  five  to  eight  da^-s.  Equally  harmless  is  the  intracutaneous  injec- 
tion of  minute  portions  of  tuberculin  (MendeP")  and  the  percutaneous 
method  of  Moro,"*"  who  anoints  the  skin  with  a  mixture  of  tuberculin 
and  lanolin.  The  conjunctival  or  opJithalmo-reaction  (Wolf-Eisner,*^ 
Calmette*-),  following  instillation  into  the  eye,  is  likely  to  provoke 
keratitis  and  is,  therefore,  objectionable.  Contrasted  to  the  subcuta- 
neous tests,  the  cutaneous  are  too  delicate  and  may  react  to  latent 
processes  not  concerned  in  producing  the  clinical  manifestations  under 
consideration;  in  addition  to  this,  the  cutaneous  test  is  at  times 
positive  when  tuberculosis  is  not  present. 

Mode  of  Infection. — Infection  with  tubercle  bacilli  is  provoked 

BY  INHALATION,  BY  INGESTION,  AND  BY  CONTAMINATION  OF  WOUNDS  AND 

ULCERS,    It  may  be  transmitted  also  from  the  mother  to  the  fetus. 

The  infection  is  consummated  as  the  result  of  the  number  and  viru- 
lence of  the  invading  bacilli  in  proportion  to  the  resistance  of  the 
host. 

The  most  frequent  mode  of  infection  is  the  inhalation  of  air  con- 
taining tubercle  bacilli,  by  means  of  which  the  excitants  gain  access 
to  the  mucous  membrane  of  the  lungs  and  are  disseminated  by  the 
lymphatics  (Cornet,*^  Hildebrand**),  while  the  upper  air  passages, 
being  more  or  less  protected  bj'  their  normal  secretions,  are  less  often 
invaded.  The  most  prolific  carrier  of  the  infection  is  the  sputum  of 
persons  affected  with  lung  tuberculosis,  although  the  bacilli  are  also 
contained  in  the  secretions  of  ulcers,  in  the  feces,  and  the  urine. 
The  contaminated  secretions  thus  gain  access  to  handkerchiefs,  floors, 
etc.,  are  dried  and  disseminated  in  the  air.  For  this  reason,  afflicted 
persons  should  be  enjoined  to  expectorate,  not  on  the  floor,  but  into 
receptacles  containing  water,  with  the  view  of  preventing  the  spread 
of  the  disease  by  these  methods  (Cornet*^).  Be^'ond  this,  the  air 
in  the  immediate  vicinity  of  patients  afflicted  with  advanced  lung 
tuberculosis,  and  who  cough  much,  is  also  contaminated  with  minute 
drops  of  fluid  that  contain  the  bacilli.     It  has  been  experimentally 


426  INFECTIONS  OF  WOUNDS 

proved   (Cornet/^  Pfeiffer  and  Friedberger/^  and  others)   that  the 
disease  is  conveyed  by  both  of  these  avenues. 

Infected  articles  of  diet  are  as  likely  to  provoke  tuberculous  lesions 
of  the  mucous  membrane  of  the  digestive  tract  as  is  the  ingestion  of 
tuberculous  sputum.  A  not  uncommon  source  of  infection  in  this 
connection  is  the  habit  some  mothers  have  of  licking  off  the  rubber 
nipples  of  nursing  bottles  and  of  chewing  various  articles  of  diet 
preliminary  to  feeding  them  to  the  infant.  Of  course  the  most  com- 
mon source  of  infection  in  infants  is  the  milk  of  cows  suffering  from 
general  tuberculosis  or  infected  udders.  The  meat  (especially  if  it 
is  not  cooked)  of  tuberculous  animals,  and  also  butter,  may  convey 
the  bacilli  into  the  alimentary  tract,  though  this  is  not  as  common 
as  obtains  with  milk.  The  danger  of  transmitting  the  disease  from 
tuberculous  mothers  to  nursing  infants  docs  not  lie  in  the  infected 
maternal  breast,  but  in  the  careless  disposition  of  the  sputum  and  in 
kissing  (Roger  and  Gamier*^). 

Fresh  and  old  wounds,  hums,  and  ulcers  are  also  invaded  by  the 
tubercle  bacilli.  The  infection  may  gain  access  to  wounds  of  the 
hands  during  operations,  at  autopsies,  while  sectioning  slaughtered 
animals,  and  when  milking  cows  whose  udders  are  tuberculous ;  and 
may  be  transferred  by  fertilized  hands  to  other  portions  of  the  body 
by  scratching,  or  into  an  already  existing  solution  of  continuity,  such 
as  ulcer  of  the  leg,  etc.  Infection  also  occurs  by  means  of  instruments 
or  foreign  bodies  to  which  tuberculous  material  becomes  attached;^ 
occasionally  a  wound  resulting  from  a  fall  is  followed  by  localized 
tuberculosis,  but  this  is  rare  and  happens  only  when  fresh  bacilli  are 
present,  as  street  dust  does  not  contain  the  excitants  of  tuberculosis 
(Cornet*^).  Secondary  infection  of  wounds  is  more  frequent  and  is 
sequential  to  unclean  manipulations  on  the  part  of  the  injured  per- 
son, such  as  moistening  plasters  with  the  tongue,  efforts  at  cleaning 
with  unsterile  textile  fabric,  etc.  To  this  class  belongs  the  infection 
which  follows  ritualistic  circumcision  when  the  wound  is  brought  in 
contact  with  the  mouth  of  a  tuberculous  Mohl. 

Tuberculosis  is  hereditary  by  conveyance  from  the  mother  to  the 
fetus,  either  directly  through  the  blood  (Huguenin*^)  or  after  the 
placenta  is  infected  {placental  infection,  Schmorl  and  Geipel*^). 
Infection  of  the  ovum  by  tuberculous  semen  {conception  infection, 
germinative  inheritance)  has  been  experimentally  studied  by  Fried- 
mann,*^  who  concludes  that  the  bacilli  may  gain  access  to  the  ovum 
with  the  semen.    Tuberculosis  may  be  accepted  as  congenital  only  in 


TUBERCULOSIS  427 

the  newhorn  (HildebrancP*)  ;  in  older  infants,  simple  contact  with 
tuberculous  parents  is  sufficient  to  contract  the  disease,  especially 
from  expelled  bacilli.  It  is  evident  to  the  clinician,  that  children  of 
iuherculous  parents  are  more  susceptible  {hereditary  disposition) 
to  tuberculosis  than  are  others,-  and  that  poor  nourishment  and  en- 
feebling diseases  increase  susceptibility  {acquired  disposition). 

Tuberculosis  is  disseminated  in  the  body  by  the  IjTnphatics  and 
the  blood.  Tubercle  bacilli  have  been  found  in  the  circulating  blood 
by  Liebermeister^'"  and  others,  not  alone  in  miliary  and  pulmonary 
tuberculosis  but  also  in  bone,  gland,  and  other  localized  infections 
(Krabbel"^).  However,  according  to  Brem,^^  confusion  in  connection 
with  similar  bacilli  contained  in  distilled  water  (Cornet  and  KosseP-), 
or  with  certain  chemical  substances,  must  be  taken  into  account ;  es- 
pecially, since  animal  inoculations  with  the  blood  of  tuberculous 
mammals  is  (because  of  its  meager  bacillar}'  content)  rarely  followed 
by  development  of  the  disease. 

Tissue  Changes. — The  inflammatory  process  provoked  by  the  invasion 
and  multiplication  of  tubercle  bacilli  at  a  certain  point  is  attended 
with  degeneration  of  cellular  elements  and  their  supporting  tissues, 
which  is  followed  b}'  proliferation  of  the  unaffected  connective  tissue 
and  a  migration  into  the  affected  area  of  leukocytes  and  lymphocytes. 
These  elements  are  the  constituents  of  the  small,  gray,  cellular  nodules 
which  Yirchow  (1852)  designated  as  tubercles.  The  nodules  are 
usually  the  size  of  a  millet  seed  and  are  surrounded  by  a  zone  of 
granulation  tissue,  the  product  of  intlammator}'  connective  tissue 
proliferation.  This  granulation  tissue  is  replete  with  tubercle  bacilli 
and  may  develop  in  response  to  the  invasion  of  the  excitants  without 
the  formation  of  the  gray  nodules. 

Tlie  changes  that  take  place  in  the  tuberculous  nodes  and  in  the  granulation 
tissue  determine  the  course  and  the  character  of  the  infection. 

The  histological  changes  attendant  upon  the  formation  of  a  tubercle 
may  be  stated  as  follows :  The  cellular  elements,  especially  the  con- 
nective tissue  cells,  proliferate  by  division,  the  endothelial  cells  of 
the  hlood  and  lymph  vessels  and,  at  times,  the  epithelial  cells  undergo 
a  similar  reproduction,  causing  an  accumulation  of  large  epithelioid 
and  fibroplastic  cells,  into  which  area  leukocytes  and  lymphocytes 
wander  from  the  surrounding  vessels  (Fig.  151).  "When  the  nodule 
is  i-ichly  invaded  by  leukoe^'tes,  to  the  relative  exclusion  of  epithelioid 
cells,  the  term  small  celled  lymphoid  tubercle  is  used  in  contradistine- 


428 


INFECTIONS  OF  WOUNDS 


tion  to  large  celled  or  epithelioid,  in  which  the  epithelioid  cells  pre- 
dominate. The  old,  distended  connective  tissue  forms  the  frame  work 
{reticulum)  of  the  tubercle.  In  the  center  of  the  nodule,  one  or  more 
multinuclear  cells  (giant  cells)  are  found.  In  these  giant  cells  the 
nuclei  are  arranged  near  the  periphery  of  the  cell  body  and  contain 
more  or  less  hacilli.  It  is  assumed  that  the  bacilli  "irritate"  the 
nuclei  into  this  extravagent  reproduction  and,  by  their  pernicious 


Fig.  151. —  Section  through  a  Tubercle. 

Upon  the  margin  of  the  tubercle  lymphoid  cells  may  be  seen ;    in  the  center 
epithelioid  cells  and  a  giant  cell. 


effect  upon  the  protoplasm,  prevent  its  production  in  proportion  to 
nuclear  division.  However,  this  viewpoint  is  not  accepted  by  all 
observers,  some  of  whom  incline  to  the  opinion  that  giant  cells  repre- 
sent individual  epithelioid  cells  which  have  fused  to  form  a  multi- 
nuclear  mass  (Ricketts^^). 

When  the  millet  seed  sized  tubercle  is  fully  developed,  its  center, 
owing  to  the  action  of  the  toxins  liberated  by  the  bacilli,  begins  to 
disintegrate  and  its  cellular  elements  degenerate  until  the  entire  for- 


TUBERCULOSIS  429 

mation  undergoes  a  hyaline  change  (coagulation  riecrosis),  v/hich  is 
finally  converted  into  a  hard  mass  consisting  of  fatty  kernels  contain- 
ing a  certain  variable  number  of  bacilli  that  ultimately  die.  Thus 
is  created  the  caseous,  opaque,  yellowish  white  tubercle.  "When  there 
is  an  overproduction  of  the  surrounding  connective  tissue,  a  fibrous 
capsule  is  formed,  or  the  degenerated  mass  is  partly  or  entirely  per- 
meated by  fibrous  tissue  (fibrocaseous  tubercle).  At  times,  lime 
salts  are  deposited  at  the  site  of  a  tuberculous  focus  and  a  calcareous 
tubercle  is  established. 

The  histological  changes  that  take  pl'ce  in  a  single  tubercle  are  the 
same  as  obtain  when  a  group  of  foci  are  simultaneously  formed, 
whether  the  process  extends  by  the  lymph  channels  or  the  infection  is 
disseminated  by  the  leukocytes.  On  section,  the  granulation  tissue 
embedding  a  tubercle  presents  a  spongy,  translucent,  grayish  red  mass 
(yellow,  when  caseous)  which,  if  disintegrated  near  the  surface  of  the 
body,  forms  ulcers  and  fistulae,  and,  in  the  deeper  parts  and  organs, 
leads  to  the  formation  of  either  caseous  or  fibrocaseous  nodules  or,  by  a 
process  of  softening  and  liquefaction,  forms  holloiv  spaces  containing 
purulent  fluid  (cavities  in  the  lungs  or  gland  abscesses).  Extension 
of  the  granulations  and  the  tuberculous  (so-called  cold)  abscesses  is  the 
result  of  the  migration  of  the  bacilli  into  contiguous  tissues  where  new 
focal  lesions  are  developed.  The  extension  of  abscesses  is  governed  by 
the  law  of  progress  in  the  direction  of  least  resistance  (commonly  fol- 
lowed by  all  fluid  exudates)  and  by  the  anatomical  arrangement  of 
loose  connective  tissue  spaces  which  determine  the  route  taken  by 
gravitation  abscesses.  In  ulcers  of  the  skin  and  mucous  membranes, 
the  nodules  are  arranged  in  pale,  flaccid,  glassy  or  yellow  granulations 
quite  visible  to  the  naked  e^^e;  in  joints,  they  cover  the  synovia  which 
forms  the  wall  of  the  abscesses. 

The  picture  of  granulation  tissue  hyperplasia  varies,  taking  on  a 
caseous,  a  purulent,  or  an  encapsidated  form  in  accord  with  the  viru- 
lence of  the  aggressors  and  the  resistance  of  the  tissues  to  which  they 
gain  access.  Koenig"'*  regards  the  form  attended  with  fibrous  tissue 
hyperplasia  as  much  less  virulent  than  the  caseous  form,  the  difference 
being  that  the  latter  is  attended  with  more  toxin  formation.  Tuber- 
culosis of  serous  cavities  and  joints  is  attended  with  seroflbrinous 
exudation. 

When  pyogenic  bacteria  gain  access  to  tuberculous  foci,  they  pro- 
voke the  manifestations  of  an  acute  inflammatory  process  with  puru- 


430  INFECTIONS  OF  WOUNDS 

lent  exudation  in  addition  to  the  picture  developed  in  response  to  the 
invasion  of  tubercle  bacilli. 

Pure  tuherculous  pus  differs  from  that  formed  as  the  result  of  pyo- 
genic infection.  Tuberculous  pus  is  the  product  of  the  liquefaction 
of  caseous  disintegration,  and  is  mixed  with  serous  and  serofibrinous 
exudate ;  it  is  not  creamy  and  smooth  like  ordinary  pus,  but  is  thin, 
and  watery,  contains  cheesy  particles — detritus,  fibrinous  flocculi — and 
is  of  a  whitish,  green  color.  Tubercle  hacilli  are  present  in  such 
small  quantity  that  this  must  be  proved  by  animal  inoculation.  The 
purulent  disintegration  of  tuberculous  granulations  and  granulation 
foci  is  not  the  work  of  the  tubercle  bacilli,  nor  due  to  the  entrance  of 
pyogenic  bacteria,  but  is  the  outcome  of  the  action  of  polynuclear 
leukocytes  which,  upon  their  death,  liberate  certain  ferments  that 
liquefy  the  degenerated  caseous  tissue  masses  by  a  process  of  digestion 
(F.  Miiller^^).  The  pus  itself  contains  very  few  pus  corpuscles  and 
is  free  from  proteolytic  ferments  (Jochmann,^®  E,  Miiller").  E. 
Miiller^^  differentiates  tuberculous  pus  from  that  of  pyogenic  origin 
by  the  excessive  albumin  content  of  the  former.  The  test  is  a  delicate 
one. 

Local  tuberculosis  is  differentiated  from  general  miliary  tubercu- 
losis; the  former,  however,  leading  to  the  latter.  A  large  proportion 
of  local  tuberculosis  belongs  to  the  domain  of  surgery, 

LOCAL  SURGICAL  TUBERCULOSIS 

A  tuberculous  focus  may  develop  at  the  port  of  entrance  of  the 
infection,  or  may,  by  hematogenous  or  lymphogenous  conveyance,  be 
established  in  a  remote  portion  of  the  body. 

A.  Tuberculosis  of  the  Skin. —  The  so-called  anatomical  tuhercle  is 
a  tuberculous  infection  of  a  wound  of  the  skin,  usually  contracted  by 
persons  engaged  in  handling  tuberculous  material  derived  from  the 
human  or  from  cattle.  It  begins  in  the  form  of  a  small,  reddish 
brown,  granular  nodule  (about  the  size  of  a  pea)  which  is  developed 
in  about  a  week.  The  lesion  is  usually  covered  with  hard,  caked 
epidermis  and  may  persist  for  years,  though  repair  usually  takes  place 
within  a  shorter  period.  The  focus  does  not  ulcerate  and  is  rarely 
attended  with  lymphatic  extension. 

Tuherculosis  cutis  (Fig.  152)  is  a  term  applied  to  a  form  of  tuber- 
culosis of  the  skin  which  is  characterized  by  a  slightly  elevated,  flat, 
mostly  round,  inflammatory  infiltration  with  a  bluish  red  edge;    is 


TUBERCULOSIS 


431 


covered  with  papillary'  projections,  and  progresses  very  slowly.  The 
process  does  not  ulcerate,  but  the  infiltrate  slowly  extends  and  may 
involve  an  entire  posterior  aspect  of  a  hand  and  invade  the  forearm. 
The  infection  occurs  most  frequently  in  persons  employed  in  slaughter- 
houses, as  the  result  of  contact  with  contaminated  meat.  When  the 
infection  persists,  the  ciibital  and  axillary  glands  are  at  times  invaded. 
Tuberculosis  ulceration  of  the  skin  occurs  (aside  from  lupus 
exulcerans)  by  extension  from  tuberculosis  mucosa  —  at  the 
mouth,  at  the  anus,  and  at  the  genitals  —  usually  in  children; 

whose  general  condi- 
tion is  much  reduced 
as  the  result  of  tuber- 
culosis elsewhere.  The 
lesions  develop  in  the 
form  of  small,  miliary 
skin  nodes  that  rapidly 
ulcerate.  These  ulcers 
have  flat,  undermined, 
phagedenous  edges, 
and  are  covered  with 
pale,  glassy  or  yellow, 
very  flaccid  granula- 
tions which  bleed  upon 
the  slightest  provoca- 
tion. Similar  ulcers 
also  form  at  the  cutan- 
eous site  of  ruptured 
deep  tuberculosis. 

The  tuberculous 
wound  infection  at  the 
prepuce  arising  in  con- 
nection with  circumcision  is  evinced  by  the  formation  of  small 
rodules  in  the  remaining  portion  of  the  foreskin  which  soon  break 
down  into  obstinate  ulcers.  In  a  few  weeks  the  inguinal  glands 
become  involved  and,  not  rarely,  general  lymphatic  and  miliary 
tuberculosis  follows. 

As  a  rule,  skin  tuberculosis  develops  in  the  form  of  minute  brownish 
red  spots  which  are  at  first  segregated  in  groups  but  gradually  coalesce 
or  form  slightly  elevated,  soft  or  hard  nodules,  varying  in  size  from 
a  pinhead  to  a  pea.     The  fact  that  their  color  does  not  disappear  on 


Fig.    152. —  Lupus 


exi'lckkaxs 
Faciei. 


ET      EXFOLIATIVUS 


432  INFECTIONS  OF  WOUNDS 

}3ressure  is  regarded  as  of  diagnostic  import.  These  spots  are  multiple 
miliary  tubercles  and  make  their  initial  appearance  in  all  the  layers 
of  the  skin  and  at  times  in  the  subcutaneous  fatty  tissue.  Often  the 
lesion  appears  singly  or  in  groups  in  a  circumscribed  portion  of  the 
skin,  at  other  times  the  spots  and  nodes  are  spread  over  wide  areas. 

The  face  is  the  most  frequent  seat  of  skin  tuberculosis  (so-called 
lupus^).  Of  100  cases,  76  involved  the  face,  of  which  38  began  on 
the  nose.  Of  the  other  parts  of  the  body,  the  extremities  are  most 
often  attacked. 

As  accidental  inoculation  of  the  skin  with  tubercle  bacilli  has  been 
followed  by  tuberculous  nodules,  especially  when  there  has  been  a 
preexisting  lesion  (such  as  eczema),  ectogenous  tuberculosis  cutis  must 
be  accepted  as  proved;  indeed.  Cornet  and  FraenkeP''  have  shown 
that  the  uninjured  skin  may  be  infected  by  friction  with  contaminated 
material,  such  as  a  handkerchief,  the  tubercle  bacilli  gaining  access 
to  a  hair  follicle  (as  obtains  with  staphylococci,  p.  194).  Konigsfeld^" 
demonstrated  the  presence  of  tubercle  bacilli  in  the  deep  layers  of  the 
skin  seven  and  a  half  hours  after  experimental  manipulations  made 
in  this  way.  Of  course,  the  infection  may  be  autogenous,  the  bacilli 
being  transferred  to  the  skin  as  the  result  of  carelessness  in  disposing 
of  sputum,  etc.  In  addition,  the  infection  may  be  conveyed  by  the 
lymph  stream  through  which  the  skin,  in  the  region  of  tuberculous 
fistulae  or  that  contiguous  to  a  caseous  lymph  node  or  bone  lesion,  is 
secondarily  invaded.  When  infection  from  infected  mucous  mem- 
branes (lips,  nose,  and  anus)  occurs,  the  bacilli  may  be  conveyed  by 
the  lymph  channels  or  may  invade  th#skin  from  contaminated  secre- 
tions. Indeed,  the  classic  form  of  lupus  of  the  face  often  begins  at 
the  nostrils  in  connection  with  tuberculosis  of  the  nasal  cavity,  extends 
to  the  nose,  the  upper  lip,  and  the  cheek,  producing  the  well  known 
"butterfly"  figure.  The  occasional  tubercle  found  in  a  scar  following 
excision  of  tuberculous  bone  lesions  is  no  doubt  due  to  transference 
of  the  bacilli  during  operations,  or  results  from  the  passage  through 
ihe  wound  of  approach  of  secretions  during  healing. 

Compared  to  these  ectogenous  and  lymphogenous  forms  of  infection, 
the  hematogenous  plays  a  subordinate  role. 

Tuberculosis  cutis,  in  accord  with  the  extent  of  the  nodular  infiltra- 
tion and  the  changes  this  undergoes,  is  characterized  by  spontaneous 


1  The  term  lupus  was  previously  applied  to  various  forms  of  phagedenic  ulcera- 
tion due  to  tubercle  bacilli.  At  present,  it  is  best  to  confine  the  term  lupus  to 
tuberculous  skin  lesions;  however,  it  would  be  still  better  to  drop  the  name 
altogether  and  employ  the  term  tuberculosis  cutis. 


TUBERCULOSIS  433 

cicatrisation,  hij  ulceration,  or  hy  reactive  tissue  hyperplasia.  It  may 
be  divided  into  lupus  disseminatus  with  discrete  insular  nodules; 
lupus  serpigiyiosus  in  wliicli  the  nodules  are  arranged  in  closely 
approximated  bow  shaped  rows;  lupus  exfoliativus  with  scaling  of 
the  epidermis,  exfoliation  or  absorption  of  the  caseous  tubercle,  and 
cicatrization;  lupus  exulcerans  with  necrosis  of  the  larger  nodules, 
the  formation  of  flat  ulcers,  and  subsequent  cicatricial  deformation  of 
the  face,  fingers,  and  toes ;  lupus  hypertrophicus  with  hyperplasia  of 
the  cutaneous  and  subcutaneous  connective  tissue  (especially  the 
lobule  of  the  ear)  or  papillary  —  verrucosus  consequent  to  hyperplasia 
of  the  papillae  of  the  skin  (on  the  extremities)  ;  and  lupus  cornutus 
with  hornlike  protrusions  of  the  epithelial  layer  of  the  cutis. 

The  chronic  course  of  lupus  (in  85  per  cent  of  the  cases,  associated 
v/ith  tuberculosis  of  organs,  bones,  and  joints)  varies  in  consistency  of 
expression,  rapidly  extending  at  one  time,  and,  at  another,  receding 
and  even  cicatrizing  in  certain  areas.  The  least  virulent  form  i-s 
characterized  by  the  formation  of  insular  nodules  which  do  not  ulcer- 
ate. When,  however,  large  areas  of  infiltration  develop,  ulceration 
usually  follows  and  leads  to  destruction  of  tissues  and  deforming  cica- 
trization. In  this  way,  the  face,  the  fingers,  and  the  toes  are  most 
severely  affected.  In  the  last  instance,  cicatricial  contraction  causes 
crippling  and  loss  of  function  of  the  part ;  in  the  face  it  causes 
ectropion  of  the  eyelids  and  mouth,  narrowing  of  the  oral  orifice,  and 
deformities  of  the  nostrils.  "When  destruction  of  tissue  is  extensive, 
the  entire  soft  parts  of  the  nose  may  ulcerate  and  be  followed  by  com- 
plete closure  of  the  apertura  piriformis.  The  ear  may  undergo  similar 
destruction  and  be  followed  by  closure  of  the  auditory  canal. 

The  contiguous  Ij'mph  nodes  are  almost  invariably  involved. 

The  erysipelatous  process  of  the  face  which  often  originates  in  a 
lupus  ulcer  {habitual  erysipelas  of  lupus)  may  have  a  beneficial  effect, 
as  it  leads  to  active  inflammation,  with  tissue  destruction  and  subse- 
quent healing.     Unfortunately,  this  is  usually  only  transient. 

Chronic  lupus,  even  cicatrized  lupus,  is,  at  times,  the  seat  of  carci- 
noma. The  latter  maj'  be  identified  by  its  dark  color,  hard  consistence, 
and  its  papillomatous  appearance. 

The  treatment  of  tuberculosis  cutis  .should  be  directed  toward  its 
early  and  complete  excision  (when  circumscribed),  and  the  removal 
of  the  subjacent  fat.  The  defect  may  be  immediately  closed  b}'  the 
transplantation  of  a  skin  flap,  as  grafting  is  (if  at  all  successful) 
followed  by  keloid  formation. 


434  INFECTIONS  OF  WOUNDS 

When  extensive  areas  are  involved,  for  instance,  the  entire  skin  of 
the  face,  excision  is  impossible.  Under  these  conditions  the  method 
of  V.  Volkmann,'^'^  which  consists  of  thorough  scraping  of  the  lupus, 
may  be  employed.  This  is  followed  by  the  application  of  the  thermo- 
cautery for  the  purpose  of  arresting  bleeding  and  of  destroying 
remaming  granulation.  The  use  of  the  hot  air  apparatus  is  often 
followed  by  exfoliation  of  the  granulations  and  subsequent  cicatriza- 
tion; however,  the  effect  is  only  transient  and  is  soon  followed  by 
recurrence  of  the  disease. 

Plastic  operations  (rhino-  cheilo-  blepharoplasty)  should  not  be 
attempted  until  the  lupus  is  entirely  healed. 

Koch's  tuherculin,  given  in  large  doses,  provokes  an  active  inflam- 
matory reaction  in  the  lupus  zone,  not  unlike  erysipelas,  followed  by 
temporary  healing.  When  tolerance  for  the  vaccine  has  heen  estab- 
lished, the  reaction  does  not  occur,  hut  new  lesions  appear  in  the  scar. 
Artificial  inflammation  may  be  provoked  by  means  of  the  Bontgen 
ray  and  also  by  the  use  of  Finsen's  light  therapy,  both  of  which  are 
followed  by  repair  if  persistently  and  intelligently  used. 

B.  Tuberculosis  of  Subcutaneous  Tissue. —  Scrofuloderma,  or 
Gumma  Tuberculosum. —  This  appears  often  in  children  in  the  form 
of  a  circumscribed,  nodular  infiltrate,  especially  contiguous  to  bone 
and  lymphatic  tuberculosis;  also,  occasionally  in  the  adult,  secondary 
to  lupus  of  the  extremities.  It  follows  the  course  of  the  lymph  chan- 
nels. The  overlying  skin  gradually  assumes  a  bluish  red  color,  thins 
over  the  dome  of  the  nodule,  and  ulcerates.  These  ulcers  are  exceed- 
ingly obstinate  and  are  covered  with  tuberculous  granulations. 

The  areas  should  be  freely  incised,  curetted  with  a  sharp  spoon,  and 
lightly  packed  with  iodoform  gauze.  If  feasible,  the  primary  focus 
should  be  removed. 

C.  Tuberculosis  of  Muscles. —  Tuberculosis  of  muscles  occurs  in  con- 
junction with  deep  ulcers  of  the  skin  and  in  mucous  membranes 
(cheek,  lips,  tongue,  etc.),  or  from  extension  of  a  bone,  joint,  or  lymph 
node  lesion.  Tuberculous  abscesses  usually  spread  through  the 
muscles,  though,  at  times,  the  muscle  itself  is  invaded.  The  process  is 
essentially  a  chronic  inflammation  of  the  intermuscular  tissues  with 
the  formation  of  tubercles  and  secondary  extension  to  the  muscle 
fibers.  Softening  and  caseation  of  large  granulation  foci  are  followed 
by  the  formation  of  abscesses,  though  fihrous  encapsulation  or  infiltra- 
tion may  also  take  place. 

Primary  hematogenous  tuberculosis  of  muscles   (myositis  tubercu- 


TUBERCULOSIS  435 

losa)  is  rare.  When  it  does  occur,  it  is  likely  to  form  large  fungoid 
and  cheesy  foci  or  abscesses.  These  areas  should  be  freely  incised 
and  scraped  out  (Lorenz®-). 

D.  Tuberculosis  of  the  Mucous  Membranes. —  Tuberculosis  of  the 
mucous  membranes  of  the  digestive  tract  and  upper  air  passages  is 
usually  secondary  to  pulmonary  tuberculosis,  the  result  of  coughing 
and  swallowing  of  tuberculous  sputum,  though  it  may  also  be  hema^ 
iogenous  in  origin. 

Primary  tuberculosis  of  mucous  membranes  is  uncommon,  yet  may 
develop  in  wounds  of  the  mouth,  at  the  lips,  the  edges  of  the  tongue, 
or  in  the  nose  when  the  bacilli  are  present  in  the  inspired  air  or  in  the 
food.  Under  these  circumstances  the  areas  of  mucosa,  denuded  of 
epithelium,  present  conditions  favorable  to  the  entrance  of  the  excit- 
ants. In  the  mouth,  injuries  produced  by  pointed,  carious  teeth,  and 
in  the  nose,  trauma  following  digital  manipulations,  often  form  ports 
of  entrance  in  this  connection.  The  process  develops  in  the  form  of 
small,  miliary  nodules,  or  takes  on  the  character  of  a  nodular  infiltrate, 
both  of  which  soon  break  down  into  exceedingly  painful  ulcers.  These 
ulcers  present  a  granular  —  often  cheesy  —  j-ellow  surface  and  have 
irregular,  undermined,  phagedenous  edges,  from  which  the  character- 
istic hardness  peculiar  to  carcinoma  is  absent.  At  times,  small  nodules 
are  present  in  the  contiguous  mucosa.  The  absence  of  induration  and 
the  presence  of  the  surrounding  nodules  are  of  help  in  differentiating 
the  process  from  carcinoma. 

The  disseminated  form  of  tuberculosis  of  the  mucosa  of  the  pharynx 
usuall}'  attends  advanced  pulmonary  tuberculosis,  but  rarely  occurs 
in  conjunction  with  infections  of  the  lips,  gums,  or  with  lupus.  The 
mucosa  is  deeply  reddened  and  gramdar  and  bleeds  freely,  especially 
when  the  nodular  infiltrate  is  converted  into  an  ulcerating  surface. 

The  faucial  tonsils  and  the  pharyngeal  tonsil  are,  because  of  their 
anatomical  construction  and  the  friction  they  are  subjected  to  in  the 
act  of  swallowing,  particularly  liable  to  infection,  especially  when  the 
tubercle  bacilli  are  present  in  large  numbers  —  as  obtains  in  cases  of 
pulmonary  tuberculosis.  However,  primary  infection  may  occur  by 
inhalation,  or  by  means  of  fertilized  articles  of  diet,  or  from  the  saliva 
of  infected  mothers  who  moisten  the  rubber  nipples  preliminary^  to 
feeding  infants.  The  latter  is  a  common  source  of  infection  in  cases 
of  extensive  cervical  gland  tuherculosis.  In  the  absence  of  ulceration, 
tuberculosis  of  the  tonsil  cannot  be  diagnosticated  except  by  micro- 
scopical examination  of  the  excised  specimen. 


43"6  INFECTIONS  OF  WOUNDS 

Middle  ear  tuberculosis  may  occur  by  extension  of  the  process  in  the 
throat  through  the  Eustachian  tube. 

Laryngeal  tuberculosis  is  usualh'  secondary  to  pulmonary  infection, 
though  the  larynx  may  also  be  pri)narUy  invaded  by  inhalation,  espe- 
cially if  the  mucosa  has  been  the  seat  of  a  chronic  inflammatory  pro- 
cess. Granulomatous  proliferation  located  on  the  vocal  cords  may 
simulate  carcinoma. 

In  the  digestive  tract,  the  lymphatic  follicles  of  the  mucosa  of  the 
gut  are  most  frequentlj^  the  seat  of  the  disease.  Prolonged  ingestion 
of  large  quantities  of  tubercle  bacilli  by  persons  afflicted  with  pul- 
monary tuberculosis  is  so  common  a  mode  of  infection,  that  90  per 
cent  of  the  cases  of  tuberculosis  of  the  respirator}^  organs  develop  the 
disease  in  the  gut.  Primary  intestinal  tuherculosis  is  very  rare 
(Cornet").  The  process  takes  on  the  ulcerative  form,  is  usually  mul- 
tiple, follows  the  course  of  the  lymph  currents  {girdle  form)  and  may 
perforate,  or  cause,  when  healed,  cicatricial  stenosis  of  the  gut.  It  is 
very  frequentl}^  located  in  the  ileocecal  region  where  it  leads  to  tumor- 
like thickening.  When  the  colon  is  infected,  and  also  when  the  dis- 
ease is  located  elsewhere  in  the  digestive  tract,  ulcerations  and  fistulae 
often  develop  at  the  anus. 

The  mucosa  of  the  urinary  tract  is  invaded  secondarih'  to  tubercu- 
lous infection  of  the  scrotum  or  kidneys.  At  times,  the  mucous  mem- 
branes of  the  entire  genital  tract  may  be  involved. 

As  tuberculosis  of  mucous  membranes  is  rarelj-  circumscribed,  the 
treatment  l)y  excision,  even  when  the  lesion  is  accessible,  can  only 
rarely  be  employed.  The  application  of  50  to  80  per  cent  of  lactic 
acid  or  of  zinc  chlorid  is  much  indulged  in.  Nodules  and  deep  ulcers 
may  be  curetted  and  cauterized. 

E.  Tuberculosis  of  Lymph  Vessels  and  Nodes. —  Almost  all  tubercu- 
lous foci  are  attended  with  the  invasion  of  the  contiguous  lymph  nodes. 
In  the  rare  instances  in  w^hich  the  primary  focus  is  not  discoverable 
(neck  and  abdominal  cavity  in  children),  the  observations  of  Orth*'^ 
and  Cornet*^  are  of  value.  According  to  these  observers,  the  mucous 
membranes  and  the  skin  may  be  traversed  by  tubercle  bacilli  without 
the  production  of  a  lesion  in  these  situations.  The  first  gland  entered 
by  the  excitants  is  at  once  occupied  with  their  destruction;  however, 
multiplication  goes  on  and  the  next  gland  is  invaded.  This  inter- 
mittent progression  going  on  from  gland  to  gland  may  be  instructively 
observed  in  animals  inoculated  with  the  bacilli   (Cornef^).     Baum- 


TUBERCULOSIS 


437 


garten*'*  states  that  the  hematogenous  deposit  of  the  bacilli  in  lymph 
nodes  is  also  possible. 

The  lymph  vessels  are,  as  a  rule,  not  affected  by  the  conveyance  of 
bacilli  containing  lymph.  However,  the  thoracic-  duct  and  the  chyle 
carriers  of  the  gut  are  not  infrequently  the  seat  of  tuberculous  infec- 
tion and,  in  some  instances,  the  lymph  vessels  of  the  extremities  are 
similarly  involved  (Jordan'^'^).  In  connection  w^ith  primary  lesions 
of  the  deeper  parts,  the  superficial  h'mph  channels  may  be  invaded 
{lymphangitis  tuhcrculosa).     This  also  occurs  in  connection  with  skin 

tuberculosis  (see 
lupus,  p.  431).  In 
these  instances,  red 
streaks  of  lymphan- 
gitis are  studded 
with  nodules  which 
break  down,  form- 
ing ulcers '  of  the 
skin  or  appear  in 
the  form  of  sub- 
cutaneous nodes 
(s  c  r  0  f  u  1  oderma) 
that  also,  at  times, 
ulcerate.  In  the  in- 
dolent form  of  h'm- 
phangitis,  the  in- 
flammatory process 
is  characterized  by 
the  formation  of  a 
cord-like  infiltrate, 
the  result  of  tuber- 
culous caseation  of 
the  walls  of  the  vessels  Avhich  may  break  down,  form  abscesses,  fistulae, 
or  deep  ulcers.  Tuberculous  lymphangitis  of  the  deep  vessels  may  be 
suspected  when  the  primary  lesion  is  located  in  some  deep  part. 

Tuberculosis  of  the  lymph  nodes  (l^miphadenitis  tuberculosa)  occurs 
at  all  ages  but  is  most  frequent  between  the  fifteenth  and  twenty-fifth 
year  of  life. 

When  the  tubercle  bacilli  gain  access  to  the  lymph  node,  it  enlarges, 
as  the  result  of  hyperplasia  of  its  cellular  elements  and  because  of  the 
development  of  tubercles.     When  the  entire  lymph  node  is  infiltrated 


Fig. 


153. —  Group  of  Tuberculous  Lymph  Nodes 
MOVED  BY  Operation. 


Ee- 


Caseous  foci  may  be  seen  upon  the  cut  surface  of  the 
nodes  and  also  showing  through  the  capsule. 


438  INFECTIONS  OF  WOUNDS 

with  coalescing  tubercles,  a  large  caseous  focus  is  formed  (Fig.  153), 
or  the  tubercles  may  break  down,  forming  abscesses  that  destroy  the 
gland  tissue  and  extend  to  the  capsule.  Invasion  of  the  capsule  is 
soon  followed  by  caseopuTmlent  infiltration  {periadenitis)  of  the  sur- 
rounding tissues  (glands,  fasciae,  muscles,  etc.)  to  which  it  becomes 
adherent.  When  the  infiltration  and  caseation  of  the  surrounding 
tissue  disintegrates,  the  process  perforates  the  skin  or  gravitation 
abscesses  are  formed,  which  perforate  into  contiguous  portions  of  the 
body  (mediastinum,  pleura,  etc.).  At  times,  the  process  extends  to 
the  internal  jugular  vein  or  the  bronchial  glands,  gains  access  to  the 
lungs  and  provokes  general  miliary  tuberculosis.  In  some  instances 
the  cheesy  masses  become  calcareous  (especially  in  the  bronchial  and 
mesenteric  glands)  and  remain  quietly  in  situ  in  the  form  of  round 
white  concretions. 

The  more  actively  large  celled  epitheloid  hyperplasia  dominates  the 
caseous  form  of  the  disease,  the  greater  is  the  likelihood  that  the 
process  will  be  confined  to  its  glandular  environment.  In  this  form, 
the  glands  appear  as  coarse,  hard  tumors  with  little  or  no  periadenitis 
(the  iion-cas€ous,  indurative  form  of  large  celled  lymph  gland  hyper- 
plasia of  Ziegler^^). 

Occasionall}'',  infected  glands  are  the  scat  of  simple  hyperplasia 
without  any,  or  with  only  a  few,  insular  tiibercles.  This  form  of  the 
process  may  be  widely  distributed  and  clinically  bears  much  resem- 
blance to  pseudoleukemia,  from  which  it  can  be  differentiated  only  by 
microscopical  identification  of  the  causative  excitants  (Falkenheim®^). 
Surgically,  tuberculosis  of  the  cervical  lymph  nodes  possesses  the 
greatest  importance,  since  they  constitute  ninety  per  cent  of  the  cases 
of  this  class.  As  the  lymphatic  channels  of  the  face,  of  the  mouth, 
and  of  the  pharj'nx  all  converge  in  the  submaxillary  region  it  is  easy 
to  understand  why  the  nodes  in  this  location  are  most  often  the  seat 
of  tuberculous  infection.  Next,  in  frequency  of  attack,  are  the  glands 
of  the  carotid  sheath  (from  lesions  in  the  mouth  and  pharynx),  the 
process  extending  along  the  internal  jugular  vein  to  the  subclavian 
triangle.  Behind  the  sternomastoid  muscles,  the  infection  invades 
the  glands  of  the  posterior  triangle. 

In  the  face,  the  lymph  nodes  lying  within  and  upon  the  parotid 
gland  ilymphoglandulae  facialis  superficiales)  may  be  infected. 

Tuberculosis  of  the  axillary  glands  proceeds  under  the  pectoral 
muscles  to  the  subclavian  triangle,  though  the  infection  may  extend 


TUBERCULOSIS  439 

downward  from  the  neck  by  the  same  route.  The  cubital  glands  are 
])riniarily  involved  from  lesions  of  the  hand. 

The  inguinal  glands  are  infected  by  lymphogenous  extension  from 
lesions  situated  in  the  extremities  and  may  be  invaded  from  the  anus. 
The  nodes  in  the  popliteal  space  are  infected  from  lesions  located  on 
the  leg  or  foot. 

In  the  ahdominal  cavity,  tuberculosis  of  the  mesenteric  and  retro- 
peritoneal glands  is  secondary  to  intestinal  ulcers ;  in  children,  the 
nodes  may  be  invaded  in  the  absence  of  infection  of  the  gut. 

Tuberculosis  of  bronchial  glands  is  important  as  an  etiological  factor 
in  the  development  of  the  disease  by  w-ay  of  the  blood  current  (miliary 
tuberculosis). 

Clinically,  the  beginning  of  tuberculosis  lymphadenitis  is  difficult  to 
recognize  w\\.QTi  only  isolated  glands  are  affected  and  the  primary  focus 
is  not  discoverable.  The  hardness  of  the  infiltrate  differentiates  it 
from  the  simple  inflammatory  processes,  but  not  from  carcinomatous 
changes  which  should  always  be  borne  in  mind  in  this  connection. 

As  the  disease  progresses,  the  sloiv  progressive  swelling  of  groups  of 
glands,  often  reaching  the  size  of  a  hen's  egg,  is  of  diagnostic  value. 
"When  peri-adenitis  gradually  causes  the  mass  to  adhere  to  the  sur- 
rounding parts,  eliminating  its  definite  demarcation,  and  this  is  fol- 
lowed by  caseation  and  liquefaction  with  the  formation  of  abscesses 
and  fistulae,  the  diagnosis  is  no  longer  difficult. 

The  rapid  increase  in  size  of  the  glandular  mass,  due  to  abscess 
formation,  may  simulate  lymphosarcoma ;  however,  the  presence  of 
small  movable  nodes  in  the  vicinity  of  the  larger  mass  indicates  the 
nature  of  the  process.  Tuberculous  hyperplasia  of  mesenteric  glands 
cannot  always  be  differentiated  from  neoplasms  in  this  situation, 
especially,  when  the  existence  of  tuberculosis  in  other  portions  of  the 
body  is  not  discoverable. 

Leukemic  glands  are  recognized  hy  the  blood  findings;  pseudo- 
leukemia (malignant  lymphomata),  by  the  fact  that  the  glands  are 
freely  movable  and  not  attended  with  peri-adenitis.  A  small,  soft 
tuberculous  gland  of  the  face,  adherent  to  the  skin,  may  simulate 
atheroma.  In  the  neck,  the  process  may  be  mistaken  for  a  dermoid 
or  brancJiiogenic  cyst.  Syphilis  of  the  glands  is  recognized  by  the 
character  of  coexisting  lesions. 

The  treatment  should  be  directed  toward  removal  of  all  the  infected 
glands,  together  with  the  primary  focus  and  improvement  of  the 
general  condition  of  the  patient.     Freely  movable  glands  may  be 


440 


INFECTIONS  OF  WOUNDS 


removed  by  blunt  dissection ;  adherent  ones,  by  excision  with  the  knife. 
Accurate  knowledge  of  the  anatomy  of  the  part  is  necessary,  as  the 
glands  are  often  adherent  to  or  surround  important  nerves  (such  as 
the  spinal  accessory)  and  veins  (such  as  the  internal  jugular).  The 
operation  wound  may  be  advantageously  tamponed  with  iodoform 
gauze  for  a  few  days  and  then  closed  in  the  usual  manner. 

Glands  left  m  situ  after 
operation  may  cause  a  re- 
currence of  the  process,  but 
need  not,  necessarily,  be  re- 
moved, as  they  often  dis- 
appear spontancousUj.  The 
results  of  operative  efforts 
at  relief  ma}'  be  stated  as 
follows :  Permanent  cure,  54 
per  cent ;  recurrences,  28 
per  cent ;  died,  18  per  cent. 
In  rare  instances,  extensive 
operative  measures  have 
been  followed  by  miliary 
tuberculosis. 

In  cases  of  enfeebled  gen- 
eral condition,  massive  glan- 
dular involvement,  exten- 
sive peri-adenitis  with  fis- 
tulae,  radical  operatiA'^e  ef- 
forts at  relief  are  contra- 
indicated.  The  fistulae  may 
be  scraped  out,  abscesses 
drained,  and  cheesy  masses 
and  granulation  tissue  re- 
moved with  the  spoon.  Large 
groups  of  glands  may  be  in- 
jected with  various  chemicals  (Lugol's  iodo-iodid  solution,  carbolic 
acid,  sublimate,  iodoform  glycerin,  etc.)  with  the  view  of  accomplish- 
ing softening.  This  is  followed  by  incision  and  curettement  with  the 
spoon  or  by  aspiration  of  the  liquid  contents.  Large  cold  abscesses 
may  be  emptied  by  puncture  and  the  area  repeatedly  injected  with 
iodoform  glycerin. 

The,  so-called,  scrofula  of  children    (Fig.   154),  represented  by 


Fig.  154. —  Illustrating  the  Condition 
which  was  forjierly  known  as  scrof- 
ULA. 

Enlargement  of  the  nodes  of  the  neck  and 
cheek  (lymphadenitis  tuberculosa),  inflamma- 
tion and  rhagades  of  the  upper  lip,  chronic 
nasal  catarrh,  conjunctivitis. 


TUBERCULOSIS  441 

CHRONIC  CATARRHAL  INFLAMMATION  OF  THE  MUCOUS  MEMBRANES, 
ECZEMA,  AND  INFLAMMATORY  SWELLING  OF  THE  LIPS,  EYELIDS,  AND 
CHEEKS,    WITH    EXTENSIVE    LYMPH    NODE    SWELLING,    especially    ill    the 

NECK,  is,  to  a  great  extent,  the  work  of  tubercle  bacilli  which  attacked 
the  already  intlamed  skin  and  mucous  membranes,  thus  gaining  access 
to  the  glands  and  causing  their  caseous  degeneration. 

A  small  number  of  cases  have  nothing  to  do  with  tuherculosis,  but 
result  from  the  entrance  of  pyogenic  excitants  through  the  inflamed 
skin  and  mucous  membrane  into  the  l^Tnph  nodes,  where  they  provoke 
h^'perplasia  or  suppuration.  Eelief  of  the  catarrhal  condition  and 
cleanliness  of  the  skin,  together  with  the  emplo^'ment  of  general 
hygienic  measures,  are  followed  by  spontaneous  recession  of  the 
glandular  swelling. 

An  additional  form  of  scrofula,  described  by  Cornet,'*^  as  pyogenic, 
may  become  converted  into  the  tuberculous  form  by  the  entrance  of 
tubercle  bacilli  which  find  a  favorable  field  for  pathogenesis  in  the 
glands  whose  resistance  is  already  lessened  by  pyogenic  aggression. 

The  term  "scrofula"  should  not  be  applied  to  cases  of  clearly 
defined  tuberculosis  of  glands,  bones  or  joints. 

F.  Tuberculosis  of  Bones  {Ostitis  Tuhcrculosa). —  Tuberculosis  of 
bones  is  usually  hematogenous  in  origin,  but  may  be  due  to  extension 
of  the  disease  from  a  primary  articular  lesion,  or  the  infection  may 
gain  access  to  bones  by  way  of  the  lymph  channels. 

The  bone  lesion  may  originate  from  a  tuberculous  process  in  another, 
more  vulnerable,  portion  of  the  body,  or  be  secondary  to  lymphatic 
tuberculosis ;  however,  there  are  cases  in  which  the  source  of  the 
infection  (even  on  autopsj^)  is  not  discoverable  (Koenig^*). 

The  role  bone  tuberculosis  plays  in  general  miliary  tuberculosis  is 
not  of  surgical  import. 

It  is  probable  that  most  tuberculous  bone  lesions  are  due  to  the 
deposit  of  dacilli  hearing  emboli  (cheesy  particles)  or  of  small  clumps 
of  bacilli  —  bacterial  emboli.  The  infarct  form  of  a  lesion  proves 
positively  its  embolic  origin  (p.  446).  The  experimental  injection  of 
tuberculous  pus  into  the  nutrient  artery  of  bones  has  been  followed 
by  development  of  tuberculous  lesions.  As  the  entrance  of  emboli 
from  the  right  heart  into  the  lung  is  followed  by  serious  lesions  (lung 
embolism),  they  must,  in  most  instances,  gain  access  to  the  left  heart 
by  way  of  the  pulmonary  veins  and  from  there  enter  the  general  cir- 
culation. It  is  also  conceivable,  that  a  lesion  in  the  lung  niight  extend 
to  a  vein,  invade  its  lumen  and,  by  the  means  just  stated,  distribute 


442 


INFECTIONS  OF  WOUNDS 


emboli  to  the  various  parts,  organs  and  tissues  of  the  body  (see  miliary 
tuberculosis,  p.  473). 


Fig.    155a. —  Femur    op    a 
Four  Weeks  Old  Child. 

The  periosteum  and  peri- 
chondrium have  been  dis- 
sected away.  The  intra- 
osseal  vessels  have  been  in- 
jected with  a  mixture  of 
mercury  and  turpentine,  and 
an  X-ray  picture  has  been 
taken,  a,  Epiphyseal  arter- 
ies; 6,  metaphyseal  arteries; 
c,  double  nutrient  arteries. 


Fig.  155&. —  Tibia  of  the 
Same  Child,  Prepared  in 
THE  Same  Way  as  Fig. 
155a. 

a,  Epiphyseal  arteries;  6, 
metaphyseal  arteries;  c,  nu- 
trient artery. 


It  is  probable  that  the  round  or  irregular  shaped  foci  and  sequestra 
are  also  often  embolic  in  origin.     The  arrangement  of  the  blood  vessels 


TUBERCULOSIS 


443 


Fig.  150. —  -\1e- 
t  a  t  a  r  s  a  l 
Bone  of  a 
New        Bokn 

IXFAXT. 


in  the  long  bones  of  youths  (Fig.  155)  indicates  that,  since  the  artery 
supplying  the  epiphyseal  centers  of  ossification  branches  toward  its 
articular  surface,  and  the  artery  of  the  metaphysis  branches  toward 
the  cartilaginous  septum  dividing  the  two  zones,  and 
since  the  nutrient  artery  of  the  diaphj'sis  sends  small 
anastomosing  branches  to  the  metaphyseal  junction,  an 
embolus  would,  of  necessity,  lodge  in  either  the  epi- 
physeal or  in  the  metaphyseal  area  of  the  long  hone. 
The  center  of  the  diaphysis  would  only  be  affected  in 
case  the  embolus  were  large  and  lodged  in  the  main 
trunk  of  the  nutrient  artery.  Fer  contra,  in  short 
tubular  hones,  because  of  the  relative  meagerness  of 
metaphyseal  arteries,  and  the  immediate  branching  of 
the  nutrient  artery  (Fig.  156),  the  diaphysis  is  most 
often  the  seat  of  embolic  invasion   (Lexer**^). 

The  infarct  type  of  ivedge  or  club  shaped  lesions  is 
the  result  of  complete  (embolic)  obstruction  of  an  arteriole  in  the 
epiphysis  or  metaphysis  of  young  bones.  This  is  made  possible  by 
the  absence  of  arterial  anastomosis  which  does  not  reach  its  full  col- 
lateral capacity  until  the  car- 
tilaginous portions  of  the  bone 
become  ossified.  Irregular 
forms  of  lesions  are  due  to  the 
deposit  of  tiny  bacterial  emboli 
or  of  minute  infected  tissue 
particles  in  the  terminal  ar- 
terial branches  or  in  the  capil- 
lary network.  Tuberculous  en- 
darteritis may  also  develop  in 
an  interosseal  artery  and  liber- 
ate bacilli  which  are  carried 
onward  by  the  blood  stream 
into  the  capillaries  of  the  bony 
structure  (Orth^^). 

The  preponderance  of  tuber- 
culous lesions  in  young   bones  Other    typical    vessels    are 

,    .      ,  .  1  in  transverse  processes. 

IS  explainable  on  the  ground  of 

their  greater  vascularity,  especially  in  the  portions  where  growth  and 
development  is  most  active.  In  the  adult,  these  regions  are  endowed 
with  relatively  few  blood  vessels. 


Fig. 


157. —  Thoracic  Vertebra  of  a  Four 
Weeks  Old  Child. 


The    most    important    arteries    pass    into 
the    body    of    the    vertebra    from    behind. 

found    in    the 


444  INFECTIONS  OF  WOUNDS 

Lesions  which  are  not  embolic  in  origin  must  also  be  regarded  as 
secondary  to  tuberculosis  situated  elsewhere  in  the  body.  The  tardy 
multiplication  of  tubercle  bacilli  compared  to  the  bactericidal  capacity 
of  the  lymph  glands  makes  it  difficult  to  assume  that  the  excitants 
could  reach  the  bone  as  the  result  of  an  accidental  inoculation  by 
means  of  a  wound,  or  by  transmigration  of  the  uninjured  skin  or 
mucous  membrane.  Most  likely,  the  bacilli  gain  access  to  the  thoracic 
duet  from  a  lesion  in  a  gland  or  to  the  blood  from  a  focus  in  the  lung, 
and  are  thus  conveyed  to  the  bone. 

When  the  clinical  manifestations  of  bone  tuberculosis  appear  in 
connection  with  trauma,  it  would  seem  fair  to  assume  that  the  injury 
provoked  into  activity  a  previoush^  existing  encapsulated  lesion  as  the 
result  of  rupture  of  the  surrounding  fibrous  tissue.  The  deposit  of 
bacilli  from  the  blood  at  the  site  of  trauma  (as  obtains  with  pyogenic 
infection  —  locus  minoris  resisteniiae)  in  cases  of  clearly  defined 
embolic  origin,  is  highly  improhahle.  The  experiments  of  Fried- 
rich"°  and  of  Honsell'^  would  seem  to  support  this  view.  Of  course 
the  coincident  deposit  of  a  tuberculous  embolus  and  the  receipt  of  an 
injury  cannot  be  excluded. 

Ostitis  tuberculosa  is  essentially,  though  not  exclusivelj',  a  disease 
of  youth.  Any  of  the  bones  may  be  affected.  Multiple  foci  are  fre- 
quent, even  in  the  same  bone,  which  is  quite  in  accord  with  etiological 
consideration,  since  single  emboli  must  be  of  rare  occurrence.  Because 
of  the  anatomical  construction  of  the  osseous  system,  the  spongiosa  of 
tubular  bones  is  most  commonly  invaded  at  its  epiphj^seal  and  meta- 
physeal areas  (in  a  manner  similar  to  what  obtains  in  pyogenic  osteo- 
myelitis). The  former  is,  perhaps,  not  as  often  invaded  as  the  latter. 
In  the  short  bones  the  reverse  obtains,  the  diaphysis  being,  also  for 
anatomical  reasons,  the  site  where  infectious  material  is  commonly 
deposited.       The    older    notiox,    that    tuberculosis    preferably 

ATTACKS  the  ARTICULAR  ENDS  OF  BOXES,  AXD  PYOGENIC  OSTEOMYELITIS 
the  DIAPHYSIS,  IS  OXLY  TRUE  AS  REGARDS  THE  EXTENSION,  NOT  THE  SEAT, 
OF  THE  PRIMARY  FOCI. 

Histologically,  the  area  where  the  tubercle  bacilli  are  deposited  in 
bone  may  be  designated  as  a  lesion  consisting  of  granulation  tissue 
and  miliary  tubercles.  The  lesion  is  at  first  grayish  red  and  trans- 
lucent, but  soon,  as  the  result  of  caseous  degeneration,  becomes  yellow ; 
the  granulations  invade  the  connective  tissue  of  the  bone  and  destroy 


TUBERCULOSIS 


445 


it  {lacunic  absorption),  establishing  a  condition  known  as  caries^ 
tuberculosa.  In  this  way  a  round  or  oval  cavity  is  formed  in  the  bone 
or  a  deep  ulcer  is  established  upon  its  surface,  both  of  which,  as  the 
result  of  the  disintegration  of  the  granulations,  are  filled  with  cheesy 
material  and  fine  particles  of  bone  (bone  sand).  As  a  rule  these 
tuberculous  bone  abscesses  remain  circumscribed,  do  not  exceed  a  hazel 
nut  in  size,  and  are  surrounded  by  an  abscess  membrane  which  is  lined 
with  tubercles.  In  addition  to  this,  the  abscess  cavity  is  often  sepa- 
rated from  the  normal  bone  by  a 
thick  layer  of  inflammatory  (sclero- 
tic) tissue.  Small  bones  like  those 
of  the  carpus  are  often  completely 
destroyed  by  caries  of  this  sort. 

When  caseous  degeneration  is 
rapid,  as  is  most  often  the  case  — 
especially  in  children  — •  cavitation 
of  a  granulation  focus  does  not  oc- 
cur. In  its  place,  there  is  at  first 
an  inflammatory  thickening  of  the 
connective  tissue  (in  which  an  entire 
epiphysis  may  be  affected),  but  soon 
the  meshes  of  the  bone  are  filled  with 
caseous  infiltrate  and  become  ne- 
crotic. Slowly,  and  more  or  less 
completely,  this  necrotic  portion  is 
separated  from  the  healthy  bone  by 
a  process  of  demarcating  inflamma- 
tion and  phagedenous  granulation, 
and  thus  a  tuberculous  sequestrum  is 
formed.  This  sequestrum  is,  smooth  or  slightly  rough,  round  or 
tubular,  yellow  in  color,  and  much  harder  than  the  surrounding 
bone  which  is  softened  by  the  action  of  granulation  tissue.  Its 
size  corresponds  to  the  outline  of  the  original  focus,  i.  e.,  about  the. 
size  of  an  egg.  When  the  sequestrum  is  not  freely  separated,  it  is 
firmly  fixed  at  its  attachments ;  if  there  is,  however,  a  combination 
of  caries  and  necrosis,  the  resultant  cavity  is  filled  with  caseous  or 
purulent  material  containing  small,  fully  separated  sequestra. 


Fig.   158. —  Vessels  in  the  Os   In 

NOMINATUM    OP    A    NeW    BoRN 

Child. 


1  Caries  in  bone  is  what  ulceration  is  in  soft  parts  —  a  progressive,  molecular 
destruction  of  substance. 


446 


INFECTIONS  OF  WOUNDS 


Externally,  the  infection  of  the  bone  is  evinced  by  sligJii  thickening, 
but  this  is  manifest  only  when  the  focus  is  superficially  located. 
Periosteal  hyperplasia  (periostitis  ossificans)  occurs  secondarily  to  foci 
in  the  cortex  of  the  bones,  especially  in  connection  with  joint  tuber- 
culosis, and  in  the  spinal  column  where  deep  ulcers  are  often  bridged 
by  proliferation  of  new  bone.  In  the  phalanges,  metacarpal,  and 
metatarsal  bones  and,  at  times,  in  the  diaphysis  of  long  bones,  the 
periosteal  proliferation  may 
present  the  picture  of  spina 
ventosa  (p.  448). 

In  the  epiphysis  of  a  long 
tubular  bone,  a  tuberculous 
focus  and  its  sequestrum  are 
often  distinctly  wedge 
shaped  (v.  Volkmann,^^ 
Koenig^^),  the  hase  directed 
toward  the  artictilar  surface, 
while  the  point  rests  near 
the  epiphyseal  cartilage  or, 
when  the  latter  has  disap- 
peared, toward  the  medul- 
lary canal,  the  result  of  the 
lodgment  of  an  embolus  in 
a  subdivision  of  an  epiphy- 
seal artery  branching  toward 

the  region  of  the  joint  sur-  yig.  159.— Tuberculous  Caries  of  the  Eim 

face.       In     rare     instances,  of  the  Acetabulum 

similar    infarct    foci    have 

been  found  in  the  skull  and 

in  the  short  bones  (Koenig, 

Krause"^)  ;  however 

pelvis,     they      occur     fre 

quently.    In  the  latter  location,  the  wedge  lies  toward  the  acetabulum 

and  the  point  is  directed  upward  and  backward  (Fig.  159). 

Diffuse  tuberculous  ostitis  occurs  when  the  lesion  is  not  confined 
within  an  abscess  membrane  nor  limited  by  a  laj^er  of  sclerotic  bone 
hj-perplasia,  but  is  surrounded  iy  a  zone  of  softened  (malacia)  hone 
suhstance  which  is  studded  with  tubercles.  This  progressive  form  of 
hone  tuherculosis  (Koenig^^)  extends  and  involves  large  sections  of 
the  bone,  or  may  rapidly  invade  its  entirety  (the  spongiosa,  the  mar- 


1,    Perforation    inward    into    the    pelvis ;    2, 

epiphyseal  cartilage;   3,  base  of  the  cuneiform 

sequestrum  corresponding  to  the  lower  branch 

of  the  nuti'ieut  artery;  4,  displacement  of  the 

T-|^     acetabular   rim   upward.      Preparation    from   a 

m   me  (,j,ji(j  twelve  years  of  age. 


TUBERCULOSIS 


447 


I 


row,  and  the  corticalis)  with  rapidly  forming  caseous  and  purulent 
infiltrate.  The  marrow  is  commonly  the  site  of  larger  or  smaller 
abscesses  {osteomyelitis  tuberculosa  purulenta) .  This  form  of  bone 
lesion  usually  occurs  secondarily  to  tuberculosis  of  a  contiguous  joint, 
though  it  may  be  primary. 

Caries  carnosa  is  a  form  of  tuberculous  ostitis,  first  described  by 
Koenig^*  in  connection  with  a  case  in  which  the  humerus  was  involved 
secondarily  to  the  shoulder  joint.  The  process  is  distinguished  by 
the  deposit  in  the  bone  of  a  flesh  colored  connective  tissue  hyperplasia. 
Spontaneous  healing  of  tuberculous  bone  lesions  by  connective  tissue 
proliferation  may  occur  when  the  foci  are  small,  circumscribed,  of  the 
granulating  type,  and  when  no  sequestrum  is  present.  The  centers 
of  the  healed  areas  usually  contain  smalt  remnants  of  granulation 

tissue  from  which 

recurrences    may 

develop  as  the  re- 
sult of  trauma.  In 
the  bodies  of  the 
vertebrae,  seques- 
tra of  considerable 
size  may  become 
encapsulated. 

Bone  lesions  may 
rupture  into  con- 
tiguous joints  or 
into  surrounding 
soft  parts.  In  the 
former  instance, 
tuberculous  arthritis  develops,  in  the  latter,  the  nature  of  the  secondary 
process  depends  upon  the  character  of  the  bone  lesion.  When  this  is 
of  the  granulating  type,  with  its  tendency  to  cicatrize,  the  disturbances 
in  the  soft  parts  will  also  be  restricted  to  connective  tissue  prolifera- 
tion. If,  however,  the  bone  lesion  is  of  the  caseopurulent  type,  the 
inoculation  of  the  process  into  the  loose  connective  tissue  is  followed 
by  the  formation  of  a  tuberculous,  or  cold  abscess,  which  extends  in 
the  direction  of  least  resistance,  often  invading  large  areas.  In  situa- 
tions where  the  bone  lesion  lies  close  to  the  surface,  the  skin  is  soon 
perforated  and  is  likely  to  be  the  site  of  ulcers  and  fistulae. 
Osteal  tuberculosis  does  not  present  the  same  picture  in  all 

BONES. 


Fig.  160. 


Wedge  Shaped  Lesion  at  Upper  End  of 
Tibia. 


448 


INFECTIONS  OF  WOUNDS 


In  the  long  tubular  hones,  the  articular  ends  are  usually  involved 
in  the  form  of  round  or  wedge  shaped  lesions  (granulalion  or  purulent 
foci  with  or  without  sequestra)  which  rupture  either  into  or  outside 
the  joint  capsule  (Fig.  160).  The  diaphysis  is  usually  the  seat  of 
circumscribed  lesions,  either  beneath  the  periosteum  or  in  the  bone 
marrow.  The  diffuse  form  of  the  disease  may  involve  large  areas  of 
the  diaphysis  (Fig.  161)  in  accord  with  the  distribution  of  the  nutrient 
artery. 

In  the  short  hones,  the  disease  usually  develops  in  the  diaphysis, 
and  as  the  corticalis  disintegrates  from  within,  and  is  encased  in  new 


Fig.  161. —  Tuberculosis  of  the  Diaphysis  of  the  Tibia  of  an  Eight 

Year  Old  Girl. 

The  foci  have  been  exposed  by  chiseling  away  a  thick  layer  of  bone.  Slight 
expansion  of  the  bone.    Sclerotic  bone  surrounds  the  foci. 

bone  produced  by  the  periosteum,  the  process  is  attended  with  much 
thickening.  The  entire  diaphysis  may  be  filled  with  cheesy  masses 
or  contain  a  large  sequestrum.  For  this  form  of  osteitis  tuberculosa 
phalangis,  metatarsi,  metacarpi,  the  term  spina  ventosa  is  often  em- 
ployed because  of  the  appearance  of  the  macerated  bone.  Osteitis 
tuberculosa  of  the  fingers  presents  a  peculiar  ''bottle  shape"  (Fig. 
162),  but  this  may  be  produced  also  by  tuberculous  periostitis. 

Of  the  short  hones,  the  vertebrae  are  most  often  attacked,  the  lesions 
being  located  in  the  anterior  portion  under  the  longitudinal  ligament, 
or  multiple  foci  may  be  distributed  throughout  the  body  of  the  bone. 


TUBERCULOSIS 


449 


When  softening  occurs,  the  weight  of  the  trunk  causes  the  vertebrae 
to  collapse  upon  each  other,  giving  rise  to  angulation  of  the  vertebral 
column  (spondylitis).  This  spinous  process  of  a  diseased  vertebra 
forms  the  point  of  the  "hump"  {malum  Pottii).  "When  several  ver- 
tebrae are  affected  the  hump  is  rounded.  Spontaneous  repair  of  these 
lesions  usually  occurs ;  as  a  rule  the  vertebral  column  assumes  a  faulty 
positi&n.  Eepair  is  attended  with  periosteal  hyperplasia  at  the  ante- 
rior aspect  of  the  spinal  column  (Fig.  163).     Spondylitis  is  frequently 

attended  with  the  for- 
mation of  granulation 
abscesses  which  often 
perforate  in  the  pos- 
terior pharyngeal  region 
or  extend  beneath  the 
fascia  covering  the  psoas 
mus'cle  perforating  the 
skin  of  the  anterior  sur- 
face of  the  thigh  {psoas 
abscess).  The  laminae 
are  rarely  involved, 
though  those  of  the  atlas 
and  axis  are  at  times  in- 
vaded by  the  disease. 

Tuberculosis  of  the 
carpal  and  tarsal  bones 
leads  to  severe  joint  in- 
fections. 

Of  the  flat  bones,  the 

Flask-like  expansion  of  the  finger  caused  by  some   fibs   are   most   often    at- 
expansion    of    the    bone    and    the    development    of         ,      ,       .,. 
masses  of  granulation  tissue.  tacked.    In  these  bones 

the  processes  usually 
take  on  the  form  of  a  superficial,  subperiosteal  lesion  which 
extends  over  a  considerable  area  or,  when  the  bone  lesion  is 
extensive,  the  process  may  result  in  the  formation  of  a  large  seques- 
trum. In  the  bones  of  the  skull  (Fig.  164),  the  parietal,  temporal 
and  frontal  bones  are  most  frequently  attacked.  The  granulating 
lesions  lead  to  sequestration  and  perforation  with  exposure  and,  at 
times,  ulcerative  destruction  of  the  dura.  The  mastoid  process  and 
the  petrous  portion  are  not  exempt  from  invasion.  Of  the  bones  of 
the  face,  the  edges  of  the  orbital  cavities  and  the  malar  bone  where  it 


r 

1 

1 

t^ 

^iS^ 

1 

■K 

.Hin^^^^B 

.  '-if.- 

1 

F'-^JhI^^I 

i 

- 

'^^^8 

1 

V'- 

L,_ 

Fig. 


162. —  Tuberculous   Osteitis   of  the  Proxi- 
mal Phalanx  of  the  Index  Finger. 


450 


INFECTIONS  OF  WOUNDS 


articulates  with,  tlie  superior  maxilla  are  the  most  frequent  sites  of 
tuberculous  lesions.  Tuberculous  ostitis  also  occurs  in  the  sternum, 
the  clavicle,  the  scapula,  and  the  ilium.  • 

Clinically,  bone  tuberculosis  is  at  first  manifested  by  more  or  less 
prolonged  pain  and  swelling.  When  the  process  extends  the  symptoms 
of  suppuration  of  soft  parts,  or  the  evidence  of  rupture  of  the  lesion 


Fig.  163. —  Tuberculous  Caries  of  the  Twelfth  Thoracic, 
First  and  Second  Lumbar  Vertebrae;  Marked  Forma- 
tion OF  Osteophytes  upon  the  Anterior  Surface  of  the 
Sacrum.     Left  half  of  the  pelvis  removed. 


into  a  joint,  are  added.  Of  course  a  cortical  lesion  is  recognized 
sooner  than  one  located  more  deeply.  A  tuberculous  abscess  in  the 
soft  parts  extends  slowly  and  without  an  attendant  inflammation  of 
the  skin  (cold  abscess).  There  is  little,  if  any,  rise  of  temperature 
when  the  process  is  purely  tuberculous  in  character.  The  presence 
of  high  fever  justifies  the  assumption  that  pyogenic  excitants  have 


TUBERCULOSIS 


451 


gained  access  to  the  lesion,  which  is  not  uncommon  in  connection  with 
fistulae,  or  it  may  indicate  the  inception  of  miliary  tuberculosis. 

The  recofjnition  of  lone  iuherculosis  is  ordinarily  not  a  difficult 
problem;  indeed,  many  localized  lesions  (for  instance,  in  the  vertebral 
column,  the  skull,  the  bones  of  the  face,  the  phalanges,  etc.)  present  a 
typical  picture  of  bone  tuberculosis.     The  chronicity  of  the  abscess 


Fig.    164. —  Extensive    Tuberculous    Destruction    of    the 
Bones  of  the  Skull,  Exposing  the  Dl-ra  and  the  Brain. 

following  the  development  of  ostitis,  the  absence  of  local  and  general 
symptoms  of  acute  inflammation,  the  gi-adual  thinning  of  the  skin  and 
its  rupture,  followed  by  the  discharge  of  thin,  flocculent  pus,  the 
development  of  persistent  fistulae  and  ulcers  with  flaccid,  yellowish 
granulations  and  undermined  edges,  and  finally  the  swelling  of  the 
nearest  group  of  lymph  nodes  should  leave  no  doubt  as  to  the  char- 


452  INFECTIONS  OF  WOUNDS 

acter  of  the  process  under  consideration.  To  this  may  be  added,  that 
bone  tuberculosis  occurs  most  often  in  enfeebled  persons  who  have 
already  given  evidence  of  the  presence  of  the  disease  in  the  lungs,  the 
glands,  the  joints,  the  skin,  or  the  mucous  membranes. 

Confusion  may  arise  in  connection  with  small  circumscribed  puru- 
lent areas  of  osteomijelitis  (subacute  or  chronic)  located  in  the  spon- 
giosa  of  the  articular  ends  of  bones.  In  the  rare  instances  of  primary 
tuberculosis  of  the  shafts  of  long  bones,  the  expansion  of  the  corticalis 
may  simulate  pyogenic  necrosis  and  abscess  formation ;  however,  the 
meager  periosteal  hj'perplasia  attendant  upon  a  tuberculous  lesion  of 
this  sort  (revealed  by  the  Rontgenogram)  is.  of  assistance  in  differ- 
entiation. In  the  absence  of  characteristic  tistulae  or  of  ulcers,  the 
diagnosis  cannot,  at  times,  he  made  until  operative  efforts  at  relief  are 
instituted,  when  the  caseous  consistence  of  the  pus,  the  round  form 
and  small  size  of  a  tuberculous  sequestrum,  contrasted  with  the  thick, 
creamy  pus  and  phagedenous,  scalloped  appearance  of  the  pyogenic 
sequestrum  (Fig.  125,  p.  288)  should  reveal  the  nature  of  the  process. 
In  doubtful  cases,  recourse  may  be  had  to  the  suhcutaneous  injection 
of  0.1  to  0.5  mg.  of  old  tuhercidin  which  provokes  a  lofial  reaction  and 
increases  its  pathogenesis  (Waldenstrom"')  :  of  course  the  discovery 
of  either  pyogenic  bacteria  or  tuhercle  bacilli  in  the  granidation  tissue, 
by  means  of  the  microscope,  is  of  great  diagnostic  import. 

The  treatment  of  bone  tuberculosis,  especially  when  suppuration  is 
established,  should  be  directed  toward  the  removal  of  accessihle  lesions. 
This  applies  to  epiphj'seal  foci  ruptured  outside  the  joint  capsule,  to 
ostitis  of  the  cranium,  the  face,  the  ribs,  etc.  The  early  removal  of 
large  epiphyseal  lesions  often  prevents  their  perforation  into  con- 
tiguous joints,  and  prompt  resection  of  foci  in  the  short  bones  tends 
to  obviate  loss  of  function  and  deformity. 

The  removal  of  bone  lesions  may  often  be  accomplished  by  means 
of  the  bone  scoop,  the  focus  being  exposed  by  free  incision  and  lateral 
displacement  of  the  periosteum.  In  other  instances  it  is  necessary  to 
enlarge  the  opening  in  the  cortex  of  the  bone  with  the  chisel  or  other 
suitable  instrument,  in  order  to  remove  sequestra  or  for  the  purpose 
of  removing  disintegrated  bone  marrow.  These  manipulations  should 
be  so  executed  that  injury  to  the  articular  cartilages  is  avoided. 
Large  bone  defects  —  for  instance,  of  the  phalanges  —  may  be  re- 
paired, after  the  wound  is  healed,  by  transplantation  of  bone.  Tuber- 
culosis of  flat  bones  such  as  a  rib,  scapula,  ilium,  etc.,  are  best  subjected 
to  sectional   resection.     Arthrectomy   is   indicated  when   joints   are 


TUBERCULOSIS  453 

involved  secondarily.  When  there  is  much  destruction  of  tissue, 
ampxiiation  may  be  necessary. 

The  treatment  of  tuberculous  abscesses  secmidary  to  bone  lesions 
depends  upon  the  location  of  the  latter.  Small  abscesses  immediately 
contiguous  to  bone  lesions  may  be  incised,  the  abscess  membrane  and 
the  bone  focus  removed,  and  the  area  tamponed  with  iodoform  gauze. 
When  the  abscess  cavity  is  large  the  wound  is  not  tamponed  but  is 
closed  by  suture  and  filled  with  a  mixture  of  iodoform  and  glycerin 
injected  through  a  space  in  the  suture  line.  This  measure,  however, 
should  not  be  used  when  the  abscess  has  spontaneously  ruptured,  nor 
when  an  acute  inflammatory  process  is  present.  Under  these  con- 
ditions the  danger  of  phlegmon  makes  free  incision  and  drainage 
necessary. 

When  an  abscess  originates  from  an  inaccessible  bone  lesion  (gravi- 
tation abscess),  incision  is  followed  b}'  a  persistent  fistula  which, 
because  of  the  discharge  of  fluid  exudate  and  the  impossibility  of  main- 
taining cleanliness,  is  in  constant  danger  of  secondary  infection  (for 
instance,  psoas  abscess).  It  is,  therefore,  justifiable  to  attempt  relief 
by  aspiration. 

For  the  purpose  of  aspirating  cold  abscesses,  a  cannula  of  large 
lumen  and  a  suction  apparatus  of  ample  power  should  be  employed, 
as  the  pus  is  likely  to  be  tenacious  and  to  contain  fibrin  flocculi  which 
tend  to  interfere  with  its  withdrawal.  "When  the  cannula  becomes 
obstructed  by  particles  of  fibrin  these  may  be  forced  back  into  the 
cavity  by  means  of  a  probe  or  other  suitable  instrument.  The  cannula 
is  best  introduced  obliquely  through  the  soft  parts  with  the  view  of 
obviating  the  subsequent  occurrence  of  a  fistula.  Aspiration  may  be 
preceded  by  a  slight  incision  through  the  skin  which  will  heal  more 
rapidly  than  a  puncture  wound  (Henle'^). 

Emptying  of  the  contents  of  the  abscess  is  followed  by  the  injection 
of  iodoform  glycerin  which  still  maintains  its  superiority  over  newer 
preparations  such  as  iodoform  ether,  carbolic  acid,  zinc  chlorid,  etc. 
The  iodoform  must  be  very  finely  powdered  and  thoroughly  mixed 
with  pure  glycerin  (10:100).  The  mixture  should  be  fresh  and  must 
be  vigorously  shaken  just  before  the  injection  is  made.  Sterilization 
of  the  mixture  is  unnecessary ;  on  the  contrary,  there  is  reason  to 
believe  that  heat  destroys  its  efficacy  and  causes  changes  in  the  iodo- 
form rendering  it  harmful.  Injections  up  to  50  c.cm.  in  quantity  (in 
children,  up  to  10  c.cm.)  may  be  introduced  through  the  cannula; 
however,  when  the  abscess  is  opened  and  the  membrane  removed, 


454  INFECTIONS  OF  WOUNDS 

absorption  by  the  resultant  fresh  surface  has  to  be  taken  into  account, 
and  the  quantity  used  should  not  exceed  10-20  c.cm.  (in  children,  2-4 
c.cm.).  Injections  may  be  repeated  at  intervals  of  from  two  to  four 
weeks.  Healing  of  the  abscess  often  takes  place  in  a  few  months  and 
a  beneficial  effect  upon  the  bone  lesion  is  also  frequently  noticeable. 
Secondar}^  infection  must  be  carefully  guarded  against ;  when  it  occurs, 
the  area  must  be  opened  immediately  and  drained. 

Fistulae  which  develop  in  connection  with  abscesses,  at  times,  heal 
after  curettage  of  the  canal,  followed  by  injection  of  iodoform 
glycerin ;  though  this  measure  may  have  to  be  repeated  several  times. 

The  dangers  of  iodoform  glycerin  injections  arise  in  connection  with 
its  use  in  excessive  quantities.  Injections  into  joint  cavities  have  been 
followed  by  severe,  and  even  fatal,  ioeloform  poisoning  (p.  72).  As 
is  to  be  expected,  the  so-called  iodoform  idiosyncrasy  is  manifested  in 
connection  with  the  injection  of  iodoform  glycerin,  just  as  it  is  when 
iodoform  gauze  is  employed  for  tamponade  of  wounds ;  particularly 
susceptible  persons  developing  a  severe  reaction  attended  with  high 
fever  fund  the  appearance  of  a  rash  on  the  skin,  etc.  In  some  instances, 
the  dyscrasia  is  manifested  by  an  increased  pulse  rate,  elevation  oE 
temperature,  and  transient  active  nephritis  w'ith  hemoglobinuria.  The 
occurrence  of  these  symptoms  is,  of  course,  to  be  regarded  as  centra- 
indicating  repetition  of  the  treatment.  The  accidental  introduction 
of  the  mixture  into  a  blood  vessel  is  likely  to  be  followed  by  necrosis. 

The  heneficial  effect  of  iodoform  glycerin  is  due,  not  to  its  meager 
bactericidal  capacity,  but  to  the  irritation  it  causes  by  its  prolonged 
presence  in*  the  tissues.  This  provokes  an  active  granxdation  tissue 
hyperplasia  that  has  a  tendency  to  contract,  thus  establishing  an  en- 
vironment in  which  new  tubercles  are  not  deposited  and  the  old  ones 
cease  to  exist.  In  addition  to  this  (according  to  Heile'^^),  the  proteolytic 
ferments  of  the  leukocytes,  attracted  hy  the  presence  of  the  iodoform, 
play  an  important  part  in  dissolving  the  disintegrated  tissues  and,  by 
protein  digestion,  render  them  susceptible  to  absorption. 

The  recognition  of  this  modus  operandi  induced  Jochmann''^  to 
assume  that  the  direct  introduction  of  ferments  would  have  the  same 
therapeutic  effect  as  resulted  from  the  attraction  of  leukocytes.  As 
leukocytic  ferment  was  difficult  to  obtain,  he  used  a  sterile  watery  1 
per  cent  solution  of  trypsin  with  0.9  per  cent  sodium  chlorid,  making 
several  injections  of  from  1-2  c.cm.  each,  which,  together  with  Batz- 
ner,'^^  he  reported  as  being  followed  by  favorable  results  in  cases  of 
tuberculous  suppurating  fistulae  and  granulating  masses  in  joints  and 


TUBERCULOSIS  455 

tendon  sheaths.  The  normal  tissues  were  supposed  to  protect  them- 
selves against  the  destructive  action  of  the  trypsin  ferment  by  virtue 
of  the  presence  of  antibodies  in  the  blood  serum  in  a  manner  similar 
to  what  obtained  wuth  respect  to  the  leukocytic  ferments.  The  injec- 
tions were  followed  by  considerable  reaction  which,  however,  was  at- 
tended with  an  increase  in  the  regenerative  processes.  Instead  of 
trypsin,  E.  Miiller'^*  suggests  that  ferment  serum  might  be  used, 
so  that  the  protective  substances  would  be  available.  Lexer^^  warns 
against  the  use  of  the  trj'psin  fluid  and  adds,  that  of  nine  cases  of  joint 
tuberculosis  in  w^hich  the  treatment  w^as  used,  eight  came  to  resection 
(reported  by  Sohler"^). 

The  injection  of  bismuth  paste  (bismuth  subnitrate  30,  wax  5,  para- 
fin  5  vaselin  60)  into  tuberculous  fistulae  is  recommended  by  E. 
Beck.^°  The  therapeutic  value  of  the  measure  is  varyingly  estimated 
(Rosenbach^^).  Lexer,^-  who  has  done  much  work  with  bone  lesions, 
denies  its  efficacy.  Fatal  poisoning,  due  to  the  formation  of  a  soluble 
albumin  combination,  has  occurred  in  several  instances.  To  avoid 
this  the  harmless  bismuth  carbonate  should  be  used.  The  entrance 
of  the  paste  into  a  vein  would  probably  be  followed  by  fatal  embo- 
lism (Brandes^^). 

In  France,  the  camphor  naplithol  preparation,  recommended  by 
Wreden,'^*  is  largely  used.  It  consists  of  two  parts  camphor  and  one 
part  b.  naplithol,  of  which  one  part  is  mixed  with  five  or  six  parts  of 
sterilized  glycerin.  The  preparation  is  used  in  the  same  way  as  iodo- 
form glycerin. 

The  course  and  character  of  bone  tuberculosis  is  believed  to  be 
favorably  influenced  by  the  X-ray  (Iselin*'),  and  also  by  exposure  of 
the  infected  part  to  sunlight  in  the  mountains  (de  Quervain^^). 

G.  Tuberculosis  of  Joints  {Arthritis  Tuberculosa). —  Tuberculous 
infection  of  joints  may  be  hematogenaus,  may  result  from  the  rupture 
of  a  contiguous  bone  lesion,  or  may  develop  secondarily  to  tuberculosis 
of  tendon  sheaths.  To  this  must  be  added,  the  possibility  of  infection 
from  contiguous  tuberculous  lymph  nodes  by  way  of  the  lymph  chan- 
nels. Tuberculosis  of  joints,  like  that  of  bones,  is  rarely  primary 
(Koenig'"'^).  The  origin  of  hemotagenous  joint  tuberculosis,  and  the 
role  that  trauma  plays  in  its  causation  are  similar  in  all  respects  to 
that  which  obtains  in  bone  tuberculosis. 

Synovial  tuberculosis  is  as  often  primary,  as  it  is  due  to  extension 
from  a  contiguous  primary  bone  lesion  and,  according  to  Koenig,^* 


456  INFECTIONS  OF  AYOUNDS 

bone  tuberculosis  is  frequently  the  result  of  extension  of  the  disease 
from  the  s^'novia. 

Joint  tuberculosis  is  essentially,  though  of  course  not  exclusively, 
a  disease  of  early  life  (first  twenty  years). 

The  knee,  hip,  and  elhoiv  joints  are  most  often  attacked,  and  in  the 
order  mentioned. 

Acute  miliar}'  tuberculosis  does  not  spare  the  joints,  and  appears 
there  in  the  form  of  multiple  foci. 

Synovial  tuberculosis  is  attended  with  the  formation  of  miliary 
tubercles  irrespective  of  whether  the  process  gains  access  to  the 
synovia  hy  way  of  the  blood  vessels,  or  is  sequential  to  intra-articular 
rupture  of  a  contiguous  bone  lesion.  In  both  instances,  the  miliary 
foci  may  be  found  lodged  in  the  granulation  tissue  lining  the  sjmovial 
sac. 

The  histological  changes  in  the  synovial  membrane  following  the 
invasion  of  tubercle  bacilli  consist  of  a  graxulatiox  tissue  hyper- 
plasia WHICH  DE\Ti:LOPS  IX  RESPOX'SE  TO  THE  CHROXIC  IXTLAMMATORY 
IRRITATIOX^,  AX'D  THE  FORMATIOX"  OF  AX  EXUDATE  IX^"  THE  JOIX'T   CAVITY. 

The  course  of  the  process  is  the  same,  irrespective  of  the  mode  of  in- 
fection; ITS  VARIATIOXS  DEPEXDIXG  UPON  THE  CHARACTER  OF  GRAXULA- 
TIOX TISSUE  HYPERPLASIA^  THE  CHARACTER  OF  EXUDATE,  AXD  THE 
CHANGES  THAT   TAKE  PLACE  IN  THE  ARTICULAR  CARTILAGES  AND  BONES, 

the  latter  being  secondarily  involved  by  extension  of  the  process  from 
within  the  synovial  pouch. 

The  tuberculous  granulation  tissue  hupcrplasia*  appears  first  upon 
the  sjTiovia  and  gradually  extends  to  the  articular  cartilages,  and 
shows  either  a  tendency  to  shrink  {dry,  or  fibrous,  granulating  form), 
or  rapidly  disintegrates  {soft,  degenerative  form).  In  the  first  in- 
stance, the  synovial  membrane  is  moderately  thickened  and  studded 
with  tubercles  (especially  the  inner  layers),  and  the  free  surface  of 
the  membrane  is  more  or  less  covered  with  pale,  grayish  red  tuber- 
culous granulation  tissue  which  only  occasionally  undergoes  caseous  or 
purulent  degeneration.  The  attendant  exudate  is  serous  or  sero- 
fibrinous in  character,  and  is  rarely  absent  in  the  early  stages  of  the 
process. 

"When,  however,  caseous  disintegration  dominates  the  situation,  the 


*Aceordincr  to  Kocnigf,54  every  tuberculous  joint  inflammation  is  attended  ^vith 
the  precipitation  of  fibrin  which  becomes  organized  and,  together  with  the  tubercles 
deposited  in  it,  forms  the  so-called  iuberciiloiis  grmiulation  tissue.  However,  not 
a  few  observers  hold  that  the  hyperplasia  of  granulation  tissue  is  primary,  and 
that  the  formation  of  fibrin  is  a  regressive  metamorphosis  (Krause"2). 


'TUBERCULOSIS  457 

synovia  is  thickly  invested  with  hj'perplastic,  soft,  spongy  granula- 
tions and  is  itself  partly  converted  into  granulation  tissue,  while,  at 
the  same  time,  the  surrounding  soft  parts  become  infiltrated  and 
edematous.  As  the  process  progresses,  circumscribed  caseous  foci  and 
abscesses  form  in  the  granulating  area  and  rupture  into  the  interior 
of  the  joint,  which  then  becomes  filled  with  purulent  exudate,  pre- 
senting the  same  conditions  as  obtain  when  a  bone  lesion  extends  into 
a  joint.  After  a  time,  the  inflammatory^  process  transmigrates  the 
s;yTiovia,  causes  the  development  of  granulation  foci  and  abscesses  in 
the  parasynovial  tissues,  and  ultimately  establishes  fistulous  openings 
in  the  skin. 

Another  suppurative  form  of  joint  tuberculosis,  which  occurs  es- 
pecially in  children  (knee  and  hip  joint),  develops  comparatively 
rapidly  in  conjunction  with  miliary  tuberculosis.  It  is  attended  with 
massive  infiltration  but  with  little  thickening  of  the  synovia,  which 
latter  is,  however,  covered  with  an  easily  removable  abscess  mem- 
brane (sj'novitis  suppurativa  tuberculosa  of  Koenig^*). 

At  times  the  knee  joint  is  the  seat  of  circumscrihcd  granulation  hy- 
perplasia attended  with  serofibrinous  exudate.  These  areas  do  not 
display  any  tendency  to  break  down  but  form  pediculated  fibrinous 
nodules  (nodular  form  of  joint  tuberculosa  fibromatosa  of  Koenig''*), 
These  nodules  are  graj'ish  red  in  color  and  contain  but  few  tubercles  or 
tubercle  bacilli. 

At  other  times  the  chronic  inflammatory  irritation  causes  a  villous 
proliferation  of  the  sjmovia  which  takes  on  an  arborescent  form  (vil- 
lous tuberculous  arthritis  Fig.  165). 

In  rare  instances,  synovial  tuberculosis,  especiall}'  of  the  knee  joint, 
has  been  found  accompanied  by  so-called  lipoma  arborescens,  the  ex- 
istence of  which  is  attributed  to  a  proliferation  of  the  villi  due  to  the 
irritation  of  chronic  inflammation.  As,  however,  this  occurs  in  other 
pathological  joints,  such  as  chronic  rheumatism,  osteo-arthritis  defor- 
mans, and  joint  sj^philis,  the  coexisting  tuberculosis  may  be  second- 
ary (Krause'^^). 

In  the  milder  forms  of  tuberculosis,  the  effusion  into  the  joints  is 
serous  in  character  {hydrops  articularis  tuberculosus  serosus  of  Koe- 
nig^*),  yellow  and  clear  or  slightly  turbid.  White  flocculi  in  the 
exudate  indicate  the  presence  of  fibrin  (In^drops  fibrinosus  of  Koe- 
nig^*).  The  fibrin  is  deposited  throughout  the  entire  joint  cavity,  es- 
pecially in  its  recesses  and  folds,  in  the  form  of  a  soft,  white  mem- 


458 


INFECTIONS  OF  WOUNDS 


brane,  which  frequently  gives  rise  to  the  formation  of  villosities  and 
free  bodies. 

The  so-called  rice  bodies,  corpora  oryzoidea,  which  occur  in  large 
quantities  in  tuberculous  joints,  resemble  tapioca  kernels;  they  are 
round,  white,  and  very  slippery,  and  are  often  attached  to  the  syno. 
via  by  threadlike  pedicles.  These  little  bodies  are  to  be  regarded 
as  the  result  of  tuberculous  inflammation,  for,  like  all  the  inflamma. 


Fig.  165. —  Proliferation  of  the  Synovial  Villi  in 
Tuberculosis  of  the  Knee  Joint.     (After  Kcenig.) 

tory  products  of  tuberculosis,  they  contain  tubercle  bacilli  and  when 
inoculated  into  animals  cause  the  development  of  tuberculosis. 

The  pediculated  rice  bodies,  according  to  some  observers,  represent 
contracted  fibrin  flocculi,  while  others  regard  them  as  particles  of 
degeneirated  synovia  {fibrinoid  necrosis).  In  either  event,  their 
presence  and  their  form  may  be  explained  on  the  ground  that  they 
are  separated  from  their  attachment  and  molded  by  the  movements 
of  the  joint. 


TUBERCULOSIS 


459 


The  occurrence  of  purulent  tuberculaus  joint  effusion  is  compara- 
tively rare,  and  its  presence  denotes  a  severe  form  of  the  infection. 

The  destruction  a  joint  undergoes  is  not  restricted  to  the  liga- 
ments and  intra-articular  cartilages  which  are  invaded  and  disinte- 
grated by  tuberculous  granulation  tissue,  but  extends  to  the  articular 
cartilages  and  contiguous  bones. 

Although  the  articular  cartilage  is  never  the  seat  of  a  primary 

tuberculous  lesion,  it  is  often  des- 
troyed iy  extension  from  the  joint 
or  from  the  hone.  Tuberculous 
granulation  tissue,  proliferating 
from  the  synovia  into  the  cartilage, 
causes  the  formation  of  cavities, 
funnel  shaped  excavations,  and 
large  defects  extending  to  the  bone. 
According  to  Koenig,^*  this  destruc- 
tion of  cartilage  is  due  primarily 
to  the  organization  of  the  fibrinous 
deposits.  The  cartilage  may  be 
destroyed  also  by  the  extension  of 
an  osseal  lesion  so  that  the  base  of 
a  sequestrum  encroaches  upon  the 
joint  and  is  worn  smooth  by  the 
movements  of  the  apposing  bones. 
Primary  sjTiovial  tuberculosis  is, 
at  times,  attended  with  the  de- 
velopment in  the  medulla  of  a  con- 
tiguous epiphyseal  spongiosa  of  a 
simple  inflammatory  granulation 
tissue  proliferation  (devoid  of  tu- 
bercle)— osteitis  granulosa — which 
is  believed  to  be  due  to  collateral 
irritation.  This  proliferation  de- 
stroys the  trabeculae  of  the  spon- 
giosa and  causes  the  formation  of  osteoblasts  and  lacunae,  thus 
making  the  affected  portion  of  the  bone  soft  and  porous.  Pres- 
ently, irregular  masses  of  granulation  tissue,  in  the  form  of  fungoid 
projections,  make  their  way  through  the  articular  cartilage  and  pro- 
trude into  the  cavity  of  the  joint,  giving  the  cartilage  a  worm-eaten 
appearance.    In  other  instances,  the  granulations  separate  the  articu- 


FiG.  166. —  Coronal  Section  of  the 
Lower  End  op  a  FEiiUR,  which 
WAS  Amputated  because  op  Ex- 
tensive Tuberculosis  op  the 
Knee  Joint. 

The  spongy  tissue  of  the  epiphysis 
has  been  transformed  into  simple 
granulation  tissue  without  tubercles 
(osteitis  granulosa).  The  articular 
cartilages  are  raised  from  the  bone 
by  this  tissue.  , 


460  INFECTIONS  OF  "WOUNDS 

lar  cartilage  from  the  bone  and  lift  it  from  the  latter  in  the  form  of  a 
hump  or,  in  the  head  of  the  femur,  in  the  form  of  a  hood ;  ultimately 
the  cartilage  disintegrates  or  becomes  stratified.  When  the  granula- 
tions of  ostitis  granulosa  (heretofore  simjjJe  in  character)  gain  access 
to  the  tuberculous  joint  area,  they  become  inoculated  with  tuberculosis 
and  tubercles  make  their  appearance  among  them.  As  the  result  of 
caseation  and  puriform  softening  these  disintegrate  and  cause  the 
destruction  of  additional  bone  tissue  {joint  caries). 

Articular  cartilages  are  promptly  destroyed  when  suppuration  oc- 
curs, or  when  they  are  subjected  to  pressure  by  masses  of  tuberculous 
granulation  tissue. 

A  special,  and  comparatively  rare,  form  of  secondary  tuberculous 
cartilage  and  bone  degeneration  occurs  without  the  formatiori  of  exu- 
dation (caries  sicca).  This  is  attended  with  the  formation  of  a  thin 
layer  of  granulation  tissue  that  has  a  strong  tendency  to  shrink  and 
at  the  same  time  to  destroy  the  cartilage  and  bone.  Under  its  influ- 
ence entire  epiphysis  is  made  to  disappear  (most  often  in  the  shoulder 
and  hip)  while  the  granulation  tissue  itself  is  converted  into  connec- 
tive tissue. 

To  the  histological  picture  of  joint  tuberculosis  must  be  added  a 
consideration  of  the  reactive  changes  that  take  place  in  the  surrounding 
parks'— including  the  connective  tissue  and  the  periosteum.  The  entire 
soft  parts,  the  capsule,  the  ligaments,  tendon  sheaths,  and  the  subcu- 
taneous connective  tissue  are  converted  by  chronic  proliferative  in- 
•  flammation  into  a  hard  nodular  mass,  which,  as  the  result  of  atrophy 
of  the  fatty  tissues  and.  of  edema,  often  takes  on  a  gelatinous 
consistence. 

After  a  time  inflammatory  irritation  also  affects  the  bones,  especi- 
ally in  the  purulent  form  of  the  disease  which  is  not  infrequently 
attended  with  the  extensive  formation  of  stalactite  shaped  osteophytes 
— the  result  of  ossifying  periostitis. 

The  mode  of  spontaneous  healing  of  joint  tuberculosis  is  of  great 
importance  in  its  bearing  on  the  employment  of  intelligent  efforts  at 
relief.  Tuberculous  granulation  tissue  has"  a  tendency  to  shrink  and 
he  converted  into  scar  tissue,  in  which  the  tubercles  are  destroyed  or 
become  encapsulated.  This  is  also  true  of  large  granulations  or  of 
caseous  lesions.  As  the  inflammatory  periarticular  tissue  also  shrinks, 
healing,  or  apparent  healing,  is  attended  with  more  or  less  loss  of 
function. 

When  the  articular  cartilages  and  the  contiguous  bones  are  only 


TUBERCULOSIS  461 

partly  destroyed  and  the  infiltration  of  the  bone  is  not  too  far  reach- 
ing, or  when  suppuration  has  not  occurred,  healing  may  still  take 
place,  the  defects  being  filled  with  new  bone  tissue;  however,  under 
these  circumstances  the  apposed  joint  surfaces  usually  coalesce  and, 
in  accord  with  the  degree  of  ossification  of  the  newly  proliferated 
tissue,  either  fibrous  or  hony  ankylosis  is  established  (frequently  in  a 
faulty  position). 

The  clinical  course  of  the  various  forms  of  joint  tuberculosis  pre- 
sents a  complexity  of  symptoms  which  are  still  farther  modified  in 
accord  with  the  particular  joint  involved. 

Generally  speaking,  the  onset  of  the  disease  is  gradual,  and  its 
course  owe  of  chronicity.  In  children,  especially  in  nursing  infants, 
it  begins  acutely,  the  knee  joint  often  being  the  scat  of  a  purulent 
tuberculous  inflammation  characterized  by  high  fever. 

The  prodro}nala  of  joint  tuberculosis  consist  of  fatigue  and  weak- 
ness of  the  limb  which,  when  a  bone  lesion  is  present,  are  supplemented 
by  deep  seated  pain.  These  symptoms  usually  persist  for  a  long  time 
before  joint  involvement  is  clearly  defined.  Not  infrequently  a  coin- 
cident trauma  or  overexertion  seems  to  precipitate  definite  expression 
of  the  disease  which,  when  it  arrives,  is  ushered  in  by  slight  fever  and 
considerable  pain  on  motion  or  palpation. 

Early  definite  signs  are,  first,  swelling,  which  varies  in  degree  in 
accord  with  the  extent  of  the  effusion,  the  thickening  of  the  capsule, 
and  the  edema  of  the  surrounding  soft  parts;  second,  loss  of  motility 
of  the  joint  and  its  fixation,  usually  in  a  characteristic  position, 
{coxitis;  abduction;  external  rotation;  gonitis;  flexion;  etc). 

At  first,  fixation  of  an  infected  joint  is  due  to  the  pain  which 
motion  causes,  the  patient  unconsciously  fixing  the  Umh  in  a  position 
which  provokes  a  minimum  of  discomfort  (Koenig''"*).  This  is  es- 
pecially noticeable  in  the  lower  extremities,  which  are,  as  a  rule,  used 
for  the  purpose  of  locomotion  as  long  as  this  is  possible.  At  times 
the  faulty  position  of  the  joint  results  from  an  effort  on  the  part  of 
the  patient  to  place  the  limb  in  a  position  which  allows  of  complete 
distention  of  the  capsule,  at  others,  the  faulty  fixation  is  due  to 
reflex  muscular  contraction.  For  these  reasons,  the  malpositions 
of  the  early  stages  of  the  disease  may  be  corrected  under  narcosis. 

Clinically,  joint  tuberculosis  is  divided  into  three  forms: 

1.  Hydrops  tuhercidosus. 

2.  Granulating  joint  inflammatian  (fungus  articuli,  tumor  alhus). 

3.  Suppurative  tuherculous  arthritis. 


462 


INFECTIONS  OF  WOUNDS 


1.     Hydrops  tuherculosus,  as  its  name  implies,  is  attended  with. 
serous  effusion,  and,  contrary  to  joint  tuberculosis  in  general,  occurs 


Fig.  167. —  Arthritis  Tuberculosa. 


most  frequently  in  adults.  It  invades  most  often  the  knee,  the  ankle, 
and  the  elbow  joint,  and  usually  is  insidious  in  its  onset;  but  at  times 
it  is  ushered  in  with  acute  symptoms.     The  process  is  manifested  by 


TUBERCULOSIS 


463 


marked  fluctuating  fluid  distention  of  the  joint  capsule  without  clearly 
defined  signs  of  tuberculosis.  Motion  is  restricted,  because  of  the 
painful  tension  of  the  peri-articular  soft  parts,  although  contractures 
are  rare. 

Aspiration  reveals  the  characteristic  tuberculous  fluid,  which  usually 
contains  fibrin  flocculi.  The  presence  of  tubercle  bacilli  in  the  fluid 
is  demonstrated  with  some  difficulty ;  a  negative  microscopical  exami- 
nation in  this  connection  is  not  determining  and  animal  inoculation 
may  be  necessary  in  order  to  establish  the  diagnosis. 

Hydrops  from  other  causes, 
such  as  chronic  gonorrhea, 
trauma,  or  such  as  are  pro- 
voked by  joi^it  mouse,  syphilis, 
and  by  extension  from 
pyogenic  lesions  in  contiguous 
epiphyses,  must  be  differen- 
tiated. 

The  process  often  recedes 
slowly  and  heals  spontan- 
eously, though  relapses  are 
frequent. 

At  times  an  effusion  of  this 
sort  is  merely  the  forerunner 
of  the  granulating  form  of 
joint  tuberculosis  and,  as  the 
fluid  slowly  recedes,  evidence 
of  the  presence  of  fungoid 
granulation  proliferation  is 
presented. 

"When  the  serous  exudate  is 
rich  in  precipitated  fibrin  content  {hydrops  fihrinosus),  manipulations 
of  the  joint  are  often  attended  with  a  peculiar  crepitation  {snowhall 
crepitus)  due  to  the  presence  of  villous,  clumpy,  or  rice  body  deposits. 
However,  fibrinous  formations  are  not  definitely  diagnostic  of  joint 
tuberculosis,  as  they  occur  also  in  connection  with  other  conditions, 
such  as  arthritis  hemophilia,  chronic  rheumatism,  and  arthritis 
deformans. 

2.  The  granulating  form  of  joint  tuberculosis  (Fig.  167)  is  very 
common.     The  development  of  granulation  masses  in  the  joint  and 


Fig. 


168. —  Tuberculous     Arthritis 
Ankle  Joint  with  Fistulae. 


OF 


464 


INFECTIONS  OF  WOUNDS 


the  inflammatory  swelling  of  the  parasynovial  tissues  give  a  charac- 
teristic appearance  to  superficially  located  joints. 

The  symmetrical  enlargement  of  the  joint  gives  it  a  spindle  shape 
which  is  more  noticeable  because  of  the  atrophy  of  the  soft  parts 
contiguous  to  it. 

The  soft  masses  of  granulation  tissue  {jaint  sponge  fungus)  often 
give  rise  to  pseudofluctuation ;  the  parasjmovial  tissues  become  hard 
and  nodular  and  the  skin  tense  and  brawny  as  the  result  of  connec- 
tive tissue  proliferation  {tumor  alhus).  When  the  proliferated  granu- 
lations show  a  tendency  to  contract,  complete  healing  is  impossible, 
the  joint  becomes  ankylosed  and,  when  preventative  measures  are  not 
employed,  fixation  in  a  faulty  position — the  result  of  shortening  of 
the  muscles  and  shrinkage  of  the  capsule  and  the  surrounding  tissues 
—takes  place.     When  the  proliferated  granulation  tissue  undergoes 


Fig.  169. —  Posterior  Luxation  of  Tibia:   Bony  Ankylosis  Following 
Healed  Tuberculosis  of  Knee  Joint. 


caseous  and  purulent  disintegration,  cihscesses  of  the  soft  parts  and 
subsequent  fistulae  develop. 

As  destruction  of  the  articular  apparatus  progresses,  and  the 
muscles  still  further  contract,  dissociation  of  the  joint  surfaces  begins. 
At  times  these  faulty  positions  are  the  result  of  the  destruction  of 
large  areas  of  hone;  for  instance,  at  the  hip  destruction  of  the  head 
of  the  bone,  or  ulceration  of  the  acetabulum,  may  be  followed  by 
posterior  upward  dislocation  of  the  femur,  and  in  the  knee,  destruction 
of  the  bone  is  often  followed  by  genu  valgum  and  varum.  On  the 
othfer  hand,  prolonged  presence  of  joint  effusion  causes  stretching 
and  relaxation  of  the  ligaments  which  may  be  responsible  also  for 
so-called  pathological  dislocation  and  suhluxations  (Fig.  169).  These 
conditions  develop  very  gradually,  and  were  designated  by  v.  Volk- 
mann  as  distcntiori  and  destruction  dislocations  and  suhluxations. 

The  early  stages  of  joint  fungus  may  simulate  osteosarcoma  growing 


TUBERCULOSIS  465 

into  tlie  joint  (both  periosteal  and  myelogenous  forms).  Differentia- 
tion is  not  easy.  The  course  of  the  disease,  the  Rontgenogram  findings, 
the  tuberculin  reaction  (p.  424),  and  perhaps  exploratory  incision 
may  be  of  aid  in  making  the  diagnosis.  A  hemophiliac  joint  or  perio- 
steal gumma  must  also  be  taken  into  account. 

3.  Suppurative  tuherciilous  arthritis,  the  cold  abscess  of  joints, 
is  comparatively  rare,  is  usually  secondary  to  a  primary  tuberculous 
synovitis,  is  chronic  in  its  expression,  and  appears  in  the  form  of  an 
effusion.  When  the  process  is  not  attended  with  pain  or  fever,  it  is 
fair  to  assume  that  the  condition  is  one  of  hydrops,  especially  when 
the  knee  joint  is  involved ;  per  cotitra,  when  fever  occurs  and  abscesses 
make  their  appearance  in  the  soft  parts,  the  diagnosis  is  clear. 

The  prognosis  of  tuherculosis  of  joints,  like  that  of  bone,  is  largely 
dependent  upon  the  general  condition  of  the  patient,  and  the  extent 
of  the  general  infection.  A  number  of  patients  afflicted  with  joint 
tuberculosis  die  of  tuberculosis  of  internal  organs,  of  amyloid  de- 
generations, and  of  exhaustion;  in  other  instances,  acute  miliary 
tuberculosis  or  a  general  infection  due  to  secondary  pyogenic  or 
putrefactive  invasion  of  fistulous  joints  stand  in  a  causative  relation- 
ship to  a  fatal  outcome. 

As  to  the  joints  themselves,  the  purulent  is  more  menacing  than 
the  sclerotic  form  of  the  disease.  Of  v.  Bruns'*^  cases  of  coxitis, 
77  per  cent  of  the  non-suppurative  recovered,  23  per  cent  died ;  of 
the  suppurative,  48  per  cent  recovered  and  52  per  cent  died.  Koe- 
nig,^*  whose  observations  are  based  on  an  immense  amount  of  material, 
reports:  In  knee  tuberculosis,  46  per  cent  of  the  suppurative  form 
and  25  per  cent  of  the  dry  form  died.  Of  these,  84  per  cent  died  within 
eighteen  years  of  tuberculosis  of  other  organs. 

Age  has  some  influence,  the  mortality  before  the  fifteenth  year 
being  somewhat  lower. 

Restoration  of  function  is  rarely  complete.  It  occurs,  at  times,  after 
hydrops.  Limitation  of  motion  is  the  rule,  complete  ankylosis  is  fre- 
quent. 

Healing,  even  with  function,  is  deceptive,  since  encapsulated  par- 
ticles of  tuberculous  tissue  are  left  behind,  which  are — only  too  often 
— provoked  into  reactivity. 

The  treatment  of  joint  tuberculosis  should  be  dominated  by  the  fact 
that  many  of  its  forms  possess  a  tendency  to  heal  spontaneously^  and, 
therefore,  operative  effort  at  relief  should  be  made  only  when  con- 


466  INFECTIONS  OF  WOUNDS 

servatism  is  not  attended  with  success,  or  when  the  character  of  the 
process  is  such  as  to  endanger  the  general  condition  of  the  patient. 

The  CONSERVATIVE  TREATMENT  IS  DIRECTED  TOWARD  THE  ATTAINMENT 
OF  HEALING  WITH  PRESERVATION  OF  THE  ARTICULAR  APPARATUS  AND 
MOTILITY  :  IF  THIS  IS  NOT  POSSIBLE,  HEALING  SHOULD  BE  PERMITTED  TO 
TAKE  PLACE  WITH  THE  LIMB  IN  A  POSITION  MOST  FAVORABLE  TO  FUNC- 
TION. 

The  chief  means  for  achieving  the  purpose  is  the  proper  application 
of  the  gypsum  bandage,  which  immobilizes  the  joint,  protects  it  from 
external  injury,  and,  by  the  moderate  amount  of  pressure  it  exercises, 
promotes  absorption.  When  contractures  are  present,  immotilization 
must  be  preceded  by  extension. 

As  the  slightest  motion  or  pressure  upon  the  joint  is  harmful, 
cases  of  joint  tuberculosis  involving  the  lower  extremities  must  be 
confined  to  bed  as  long  as  the  joint  is  painful  upon  pressure  or  the 
temperature  is  above  normal.  The  gypsum  cast  should  be  changed 
every  six  to  eight  weeks,  the  skin  cleansed  and  covered  with  salve  or 
powdered  with  the  view  of  preventing  dermatitis.  If  fistulae  are 
present,  these  are  uncovered  by  suitable  openings  cut  in  the  gypsum 
for  the  purpose  of  allowing  of  cleansing  and  frequent  changes  of 
dressings. 

When  the  initial,  painful  stage  of  the  disease  is  overcome  (usually 
after  months)  and  the  swelling  has  disappeared,  the  limb  is 
encased  in  an  appropriate  immobilizing  apparatus  and  the  patient  is 
permitted  to  leave  the  bed.  However,  the  apparatus  must  be  arranged 
so  that  the  joint  is  absolutely  immobilized  in  the  proper  position 
without  the  exercise  of  undue  pressure.  A  discussion  of  gypsum 
bandages  does  not,  of  course,  belong  here;  however,  it  may  not  be, 
amiss  to  state  that  the  character  of  material  used  is  a  matter  of  con- 
siderable importance. 

When  healing  has  progressed  so  that  all  signs  and  symptoms  of  the 
disease  have  disappeared,  it  is  advisable  to  fit  the  part  with  light  re- 
movable apparatus  with  the  view  of  preventing  contractures.  This 
apparatus  may  consist  of  light  gypsum,  wood,  celluloid,  silicate  of 
soda,  starch,  etc.,  etc. 

The  correction  of  contracture  malpositions  (which,  in  most 
cases,  exist  before  treatment  is  begun),  when  due  to  reflex 
muscle  contraction  or  to  moderate  sclerotic  shrinkage,  may  be  ef- 
fected in  a  few  days  by  extension  with  weights  (Buck's  extension) 
(p.  739)  or,  when  the  case  is  ambulatory,  the  deformity  may  be  over- 


TUBERCULOSIS  467 

come  by  carefully  applied  force,  under  narcosis,  and  the  part  immedi- 
ately immobilized. 

When  contractures  are  severe  and  are  attended  with  shortening  of 
the  muscles  and  atrophy  of  the  soft  parts,  gradual  stretching  hij  ex- 
tension should  be  employed.  Forcible  correction  (brisement  force)  is 
objectionable  because  of  the  danger  of  rupturing  an  encapsulated 
lesion,  causing  local  extension  of  the  process  or  the  development  of 
general  miliary  tuberculosis.  However,  when  the  measure  is  emploj-ed, 
for  instance  in  ambulatory  cases,  it  must  be  carefully  executed  in 
several  sittings  and  the  part  immobilized  between  treatments. 

Fibrous  or  bon}^  ankylosis  in  faultj^  positions  demands  operative 
measures  of  relief  (resection  of  the  joint  or  corrective  osteotomy). 

Intra-articular  medication  is  a  useful  measure,  as  it  favors  the 
shrinkage  of  granulation  tissue  (v.  Bruns,*"  etc.)-  Of  the  various 
agents  used,  none  has  been  productive  of  better  results  than  follow 
the  use  of  10  per  cent  iodoform  in  pure  glycerin  (v.  Bruns*').  For 
the  purpose,  the  joint  is  emptied  by  aspiration  and  10  to  20  c.cm.  (in 
children,  5-10  c.cm.)  of  the  mixture  injected  into  it.  Light  massage 
or  kneading  disperses  the  fluid.  When  fungoid  masses  are  present, 
small  injections  are  made  in  several  places.  The  treatment  may  be 
repeated  every  two  to  four  weeks ;  if  exudate  has  accumulated  in  the 
interim,  this  is  removed.  The  joint  should  be  immobilized  between 
treatments.    Asepsis  must  be  carefully  observed. 

Para-articular  abscesses  and  fistulae  maj^  also  be  injected  with  the 
iodoform  glycerin  mixture. 

In  cases  of  so-called  iodoform  idiosyncrasy,  two  to  three  per  cent 
carbolic  acid  solution  or  camphonaphthoglycerin  may  be  used. 

The  conservative  treatment,  which  is  often  advantageously  com- 
bined with  iodoform-glycerin  injections,  should  be  used  in  all  fresh 
cases  and  may  also  he  tried  in  old  ones.  When  the  local  lesion  ex- 
tends or  the  general  condition  is  failing,  it  is  proper  to  assume  that 
the  tuberculous  process  is  progressing,  and  that  large  areas  are 
being  involved.  In  this  connection  radiographic  examinations  are 
very  helpful.  Under  these  conditions  the  employment  of  operative 
measures  of  relief  should  promptly  displace  the  conservative  treat- 
ment. 

Conservative  treatment  is  contra-indicated  in  cases  complicated  by 
bone  tuberculosis,  abscesses,  fistulae,  and  pathological  luxations;  also 
when  the  general  condition  of  the  patient  is  unfavorable  and  when 
pyogenic  or  putrefactive  infection  is  added  to  the  tuberculous  process. 


468  INFECTIONS  OF  WOUNDS 

The  duration  of  the  conservative  treatment  extends  usually  over 
several  years,  during  whieh  exacerbations  of  the  process  occur  at  not 
infrequent  intervals. 

The  best  results  of  conservative  treatment  are  obtained  in  patients 
under  fifteen  years  of  age.  Henle'^*  reports  that  in  tuberculosis  of 
the  large  joints  in  patients  under  that  age,  79.3  per  cent  heal,  while 
after  that,  repair  occurs  in  62.5  per  cent  of  the  cases. 

Bier,®^  basing  his  conception  on  the  fact  that  persons  suffering 
from  pulmonary  congestion — such  as  occurs  in  cardiac  disease — 
possessed  a  certain  immunity  against  lung  tuberculosis,  conceived  the 
idea  that  passive  congestion  would  exercise  a  beneficial  effect  upon 
bone  and  joint  tuberculosis.  For  the  purpose,  the  proximal  portion 
of  the  affected  limb  is  daily  encircled  with  a  rubber  constriction 
bandage  which  is  left  in  situ  for  one  or  more  hours.  There  is  much 
difference  of  opinion  with  regard  to  the  beneficial  effect  of  the  meas- 
ure. In  any  event,  it  should  be  used  only  in  the  early  stages  of 
the  disease  when  the  congestion  it  produces  might  have  a  ten- 
dency TO  increase  connective  tissue  proliferation.  In  the  pres- 
ence OF  suppurative  disintegration  of  tissue,  its  use  is  contra- 
indicated  (Lexer^^).  This  view  is  shared  by  a  number  of  observers. 
In  experimentally  produced  joint  tuberculosis,  the  measure  has  not 
proved  of  value  (v.  Baumgarten^").  Recently,  Bier  suggests  main- 
taining the  constriction  hyperemia  for  twelve  hours  daily,  and  the 
administration  of  large  doses  of  potassium  iodid  with  the  view  of 
lessening  the  danger  of  suppuration. 

The  operative  treatment  of  joint  tuberculosis  is  indicated  in  cases 
in  which  the  coexistence  of  tuberculosis  elsewhere  in  the  body  and 
the  extent  of  the  local  process  makes  the  employment  of  the  conserva- 
tive method  impracticable,  and  in  cases  in  which  the  local  process 
shows  no  improvement  after  the  latter  has  been  given  a  trial.  The 
operation  should  be  executed  with  the  part  exsanguinated  by  means 
of  the  V.  Esmarch  bandage  (p.  36),  and  the  incision  should  be  so 
located  as  to  attain  the  widest  possible  exposure  of  the  joint.  All 
diseased  parts  should  be  removed  with  the  knife,  scissors,  and  spoon. 
After  the  entire  synovia  is  removed,  the  articular  surfaces  of  the 
bones,  the  bones  themselves,  the  ligaments,  and  the  contiguous  soft 
parts  should  be  searched  and  diseased  foci  removed.  This  form  of 
procedure  (arthrectomy  synovaUs)  suffices  for  many  cases;  however, 
in  those  in  which  the  articular  cartilages  and  the  epiphysis  are  in- 
volved, resection  of  the  joint  must  be  resorted  to   {arthrectomy  oss- 


TUBERCULOSIS  469 

alis).  In  young  persons,  as  much  of  the  cartilaginous  substance  as 
possible  should  be  saved  in  order  to  conserve  the  growth  of  the  bone. 
In  some  cases  the  lesion  may  be  excised  without  opening  the  capsule  of 
the  joint  {extracapsular  resection).  In  any  event,  the  removal  of 
diseased  tissue  must  he  thorough. 

After  the  complete  hemostasis  the  operative  wound  may  be  closed 
by  suture ;  deep  pockets  are  drained.  Healing,  which  occurs  in  about 
two  mouths,  is  accomplished  by  means  of  fibrous  union  with  slight 
retention  of  function,  or  by  bony  union  with  complete  ankylosis.  The 
tendency  toward  contractures  makes  it  imperative  (especially  in  chil- 
dren) that  immobilization  be  maintained  for  a  long  time  with  light 
apparatus. 

In  a  certain  number  of  cases  amputation  is  justifiable  in  cases  of 
advanced  tuberculosis  in  other  portions  of  the  body  (especially  in 
the  aged)  ;  as  when  the  process  has  invaded  large  areas  of  bone,  or 
when  pyogenic  infection  is  an  added  complication. 

An  additional  form  of  joint  tuberculosis  is  described  by  Poncet  and 
Leriche^''  to  which  they  give  the  name  "rheumatisme  tuberculose. " 
It  occurs  in  tuberculous  persons  in  the  form  of  an  acute  or  chronic 
joint  rheumatism.  The  joints  are  sequentially  involved  and  heal  with 
more  or  less  complete  ankylosis.  Lexer®-  speaks  of  seeing  a  case 
which  followed  excision  of  tuberculous  Ij'mph  nodes ;  later,  fatal  acute 
miliary  tuberculosis  developed.  The  nature  of  the  process  can  be 
demonstrated  onl}-  b}"  microscopical  examination  of  portions  of  joint 
capsule.  The  prognosis  is  unfavorable,  but  depends  upon  the  virulence 
of  the  bacilli.  Melchior^^  was  able  to  find  the  tubercle  bacilli  in  the 
circulating  blood  of  a  case  of  this  sort. 

It  is,  of  course,  reasonable  to  assume  that  patients  afflicted  with 
tuberculosis  ma}'  have  transient  disturbances  of  the  jomts  occur 
at  intervals  without  the  development  of  clinical  synovial  tuberculosis, 
and,  indeed,  clinicians  are  not  infrequently  confronted  with  evidence 
to  this  end.  Theoretically,  there  is  no  reason  why  manifestations  of 
this  sort  may  not  be  due  to  the  presence  of  tubercle  bacilli  in  the 
blood.  As  greater  efforts  are  made  to  recognize  the  precise  character 
of  inflammatory  lesions  in  joints,  no  doubt  the  tubercle  bacillus  will 
be  found  more  frequently  the  causative  excitant  in  this  connection. 

H.  Tuberculosis  of  Tendon  Sheaths  and  Bursae. —  Tuberculosis  of 
tendon  sheaths  and  bursae  appears  in  many  transitional  forms ;  how- 
ever, a  subdivision  into  four  classes  may  be  made  as  follows : 

1.     Hydrops  tuhcrculosus  serosus,  tuberculous  hygroma:    The  walls 


470  INFECTIONS  OF  WOUNDS 

of  the  sheath  covered  with  tuberculous  granulations  and  attended  with 
a  serous  exudate. 

2.  Hydrops  tuherculosus  serofihrinosus,  rice  tochj  hygroma:  The 
walls  of  the  sheath  covered  with  tuberculous  granulations  and  fibri- 
noid proliferative  villosities;  the  attendant  exudate  moderate  in 
amount  and  serous  in  character;  rice  bodies  are  present  in  small  or 
large  numbers  (Fig.  170). 

3.  Granulating  form  {fungus)  with  sclerosis:  Connective  tissue 
proliferation  and  thickening  (1-2  c.cm.)  of  sheath,  little,  if  any, 
exudate;  at  times,  nodules  as  large  as  pigeon's  eggs  and  granulomata. 

4.  Granulating  form  with  suppuration  {cold  abscess) :  Sheath 
lined  wuth  cheesy  granulations;  suppuration;  external  rupture. 

These  various  forms  may  be  primary,  may  follow  trauma,  may  occur 
simultaneously  in  several  locations,  or  may  result  by  extension  from 


Fig.   170. —  Eice  Body  Hygroma  of  a  Bursa  of  the   Shoulder. 

tuberculosis  of  a  bone  or  joint.  Tendovaginitis  tuberculosa  occurs 
most  frequently  in  the  upper  extremities,  usually  involving  the  flexor 
tendons  at  the  wrist.  On  the  back  of  the  hand,  the  synovial  sac  of 
the  second  and  fourth  is  frequentlj^  invaded.  In  the  foot,  the  tendons 
of  the  dorsum  are  more  often  infected  than  those  of  the  plantar  area. 
Primary  bursitis  tuberculosa  may  occur  anj-^vhere  in  the  body,  but  is 
most  often  secondary. 

The  course  of  the  process  is  chronic.  Kadiating  pain,  restriction  of 
motion,  feebleness  of  the  affected  limb,  and  the  appearance  of  slowly 
developing  flat,  enlongated  swellings  which,  an  motion,  demonstrate 
their  connection  with  the  tendons,  characterize  the  disease.  The  hour- 
glass swelling  (hygroma)  at  the  wrist  which  is  due  to  constriction  of 
the  dis'tended  synovia  by  the  ligamentum  carpi  volare  transversum 
is  of  diagnostic  value. 

Recognition  of  the  primary  forms  is  more  difficult  than  obtains 


TUBERCULOSIS  471 

when  the  process  is  secondary  to  tuberculosis  of  contiguous  bones  or 
joints.  The  crepitation  produced  by  the  rice  bodies,  the  palpation  of 
fluctuating  areas,  and  the  presence  of  friction  when  the  tendons 
are  actively  moved,  ma}'  be  regarded  as  diagnostic.  In  the  suppura- 
tive form  of  the  disease,  the  establishment  of  fistulae  occurs  so  soon 
that  there  should  be  no  difficulty  in  identifying  the  process.  How- 
ever, differentiation  in  cases  of  simple  hydrops  is  not  so  easy,  since 
this  form  of  tendovaginitis  also  follows  trauma  and  may  be  due  to 
chronic  irritation,  rheumatism,  gonorrhea  or  syphilis.  In  this  form  of 
the  disease  the  coexistence  of  tuberculosis  elsewhere  in  the  body  may 
be  advantageously  taken  into  account.  The  granulating,  non-suppur- 
ating form  appears  in  the  tendon  sheaths  as  a  pseudofluctuatuig  or 
nodular  elongated  mass.  Although  lipoma  arhorescens  gives  the 
same  signs,  it  is  so  rare  as  to  permit  of  its  exclusion.  Hard  nodules 
in  the  synovia  may  simulate  tumors  of  various  kinds;  this  applies  also 
to  deeply  located,  heavily  infiltrated  and  distended  hygromatus 
bursae. 

The  treatment  in  the  serous  form  may  be  carried  out  along  the 
lines  laid  down  in  connection  with  the  conservative  treatment  of  joint 
tuberculosis,  i.  e.,  aspiration  of  the  fluid  contents  and  the  injection  of 
iodoform  glycerin  (p.  467).  In  the  other  forms  of  the  disease,  the 
operative  treatment  may  be  employed.  The  sacs  are  widely  opened 
and  the  deposit  of  fibrin,  rice  bodies,  etc.,  removed ;  after  which  the 
wound  is  sutured  and  iodoform  glycerin  is  injected  between  the  last 
two  stitches.  In  tendovaginitis,  active  motion  is  encouraged  after  the 
tenth  day  following  the  operation.  Good  function  may  be  expected, 
provided  the  tendon  itself  has  not  undergone  destruction. 

I.  Tuberculosis  of  Serous  Cavities  and  Internal  Organs. — Tuberculosis 
of  serous  cavities  and  the  large  vital  organs  is  of  interest  only  in 
connection  with  operative  measures  of  relief. 

The  thoracic  cavity  is  attacked  for  the  relief  of  tuhcrculous  pleuri- 
tis  when  its  fluid  exudate  causes  menacing  pressure  upon  the  lung. 
For  the  purpose,  aspiration  or  the  resection  of  one  or  more  rihs  fol- 
lowed hy  drainage  may  be  employed.  The  process  is  rarely  primary, 
but  is  not  infrequentl}'  due  to  extension  from  tuberculosis  of  the 
lung,  the  vertebrae,  or  the  ribs,  or  it  may  occur  as  a  part  of  a 
general  miliary  tuberculosis. 

Tuherculous  peritonitis,  which  occurs  frequently  in  children  sec- 
ondary to  infection  of  the  mesentric  retroperitioneal  lymph  nodes,  of 
the  gut,  and  of  other  abdominal  organs,  may  also  be  subjected  to 


472 


INFECTIONS  OF  WOUNDS 


operative  measures  of  relief.  The  operation  consists  of  opening  the 
peritoneal  sac,  the  beneficial  effect  of  which,  aside  from  removal  of 
the  exudate,  is  ascribed  to  the  hyperemia  provoked  by  the  manipula- 
tions of  the  abdominal  contents. 

Of  the  organs,  the  kidney,  the  urogenital  apparatus  (Fig.  171),  the 
thyroid  gland,  the  mammae,  and,  when  favorably  located  the  lung 
are  subjected  to  operative  efforts  at  relief  when  they  are  the  seat  of 
tuberculous  lesions . 


Fio.  171. —  TuBERCiTLOSis  Testis. 


General  Treatment  in  Local  Tuberculosis. — The  surgical  treatment  of 
local  tuberculosis  must  be  supplemented  by  general  treatment  of  the 
patient  which  consists  of  measures  directed  toward  maintaining  gen- 
eral resistance. 

The  most  important  measure  in  this  connection  is  the  administration 
of  easily  assimilated  food  given  at  frequent  intervals.  The  patient 
should  spend  as  much  time  as  possible  in  the  open  air.  Under  no 
circumstances  should  patients  of  this  sort  live  in  quarters  where  they 


TUBERCULOSIS  473 

are  exposed  to  reinfection  or  liable  to  transmit  the  disease.  When 
possible,  they  should  be  placed  in  especialh"  arranged  sanatoria  in 
the  mountains  or  at  the  seashore.  Residence  in  a  warm  climate  is 
desirable  (Cornet"*^).  Bathing,  massage,  and  moderate  exercise  are 
of  unquestionable  value. 

Of  the  various  medicinal  remedies,  creosote  and  arsenic  are  much 
employed.  The  use  of  tuherculin  (p.  424)  would  seem  to  deserve 
serious  consideration.  The  so-called  antituberculosis  serum  of  Mar- 
morek^-  is  of  doubtful  efficacy  (Hohmeier,^^  Kaufmann"*). 

The  beneficial  effect  of  sunlight  in  high  altitudes  (heliotherapy), 
even  in  local  tuberculosis,  has  been  extolled  by  Bardenheuer,^"  Rol- 
lier,®®  de  Quervain,^'"  "Wittmer,^"  Franzoni,®*  and  others.  As  the 
action  of  sunlight  is  dependent  upon  its  ultraviolet  rays,  Koenig'^* 
recommends  the  use  of  quartz  lamps  when  exposure  to  the  sun's  rays 
is  impracticable. 

ACUTE  GENERAL  MILIARY  TUBERCULOSIS 

Tubercle  bacilli  may  invade  the  blood  in  such  an  overwhelming 
quantity  that  instead  of  the  insular  lesions  that  usually  occur  in 
connection  with  hematogenous  tuberculosis,  a  widely  disseminated 
development  of  miliary  tubercles  in  the  various  parts,  organs  and  tis- 
sues of  the  body  takes  place,  in  which  the  large  vital  organs,  the  joints, 
the  bones,  and  the  serous  cavities  are  most  largely  invoh'ed.  As  death 
usually  occurs  in  a  short  time,  the  pathogenesis  of  this  form  of  tuber- 
culosis is  of  no  surgical  import. 

The  process  is  not  the  result  of  multiplication  of  tubercle  bacilli  in 
the  blood,  but  is  due  to  their  sudden  liberation  from  a  lesion  in  the 
tharacic  duct,  in  a  pulmonary  vein  or  artery,  in  the  endocardium,  or  in 
a  similar  location. 

In  the  walls  of  vessels,  a  tubercle  develops  in  two  ways :  The  bacilli 
are  deposited  in  the  intima  by  the  blood  current  or  through  a  vasa 
vasarum  (endarteritis  tuberculosa)  ;  or  a  tuberculous  lesion  ruptures 
into  the  lumen  of  a  vessel  (periarteritis  tuberculosa).  The  latter 
occurs  in  connection  with  tuberculosis  of  bronchial  and  mesenteric 
glands,  or  of  the  lungs,  the  bones,  and  the  joints.  It  has  occurred  in 
lupus.  The  result  is  either  rupture  of  the  blood  vessel  or  the  forma- 
tion of  cirsoid  aneurism.  An  operative  effort  at  relief  of  a  local  lesion 
has  been  followed  by  a  general  infection  (Wittmer^^). 

The  typhoid,  pulmonary,  and  meningeal  forms  are  differentiated  by 


474  INFECTIONS  OF  WOUNDS 

the  special  symptoms  indicative  of  involvement  of  the  gut  (diarrhea 
and  intestinal  bleeding),  of  the  lung  (d^^spnea,  cyanosis,  cough),  and 
of  the  meninges  (muscular  rigidity,  convulsions,  unconsciousness  and 
delirium).     As  a  rule  the  disease  is  attended  with  high  fever. 

Patients  succumb  in  a  short  time  —  a  few  hours  to  several  months. 
Recovery  is  practically  impossible. 

BIBLIOGRAPHY 

1.  Klencke.     Quoted  by  Vullamin  No.  2. 

2.  ViLLAMix.     Gaz.  hebdom.,  1865. 

3.  Koch.     Berlin,  klin.  Woch.,  1882,  and  Mittl.  a.  d.  kais.  Gesundheitsamt., 

1884. 

4.  V.  Baumgartex.     Virchow's  Arch.  Ixxxii. 

5.  Koch.     Deutsch.  med.  Woch.,  1901. 

6.  KossEL.     Zentrbl.  f.  Bakt.,  Ref.  Bd.  39, 1907-1910,  Ref.  Bd.  46, 1910. 

7.  Heuss  und  Weber.     Zentrbl.  f.  Bakt.  Orig.  Bd.  64,  1912. 

8.  V.  DuNGERi^.     Miincb.  med.  Woch.,  1906. 

9.  Ebers.     Zentrbl.  f.  Bakt.,  1909,  Orig.  Bd.  59,  1911. 

10.  BuRKARDT.     Deutscb.  Zeitscbr.  f.  Cbir.,  Bd.  106,  1910. 

11.  A.  Weber.     Miincb.  med.  Wocb.,  1907. 

12.  Corxet  and  Kos^el.     In  Kolle-Wassermann  Handb.  d.  path,  Microorg. 

2d  ed.,  Bd.  5,  1913. 

13.  Klein-.     Zentrbl.  f .  Bakt.,  1890. 

14.  XocARD  ET  Roux.     Ann.  de  I'inst.  Pasteur,  1887. 

15.  Hiss  and  Zinsser.     Text  Book  of  Bact.,  N.  Y.,  1916. 

16.  BiENSTOCK.     Fortsch.  d.  Med.,  1886.  » 

17.  ZiEHL.     Deutsch.  med.  Woch.,  1883. 

18.  Uhlenhuth.     Beriin.  .klin.  Woch.  No.  29,  1908. 

19.  RosENAU.     Prevent.  Med.  and  Hvg.,  N.  Y.,  1913. 

20.  Erlich.     Deutsch.  med.  Woch.,  1882. 

21.  Pappenheim.     Berlin,  klin.  Woch.,  1898. 

22.  Petropf.     Johns  Hopkins  Hosp.  Bulb  xxvi,  No.  294,  1915. 

23.  Theobald  Smith.     Jr.  Exp.  Med.,  1898,  iii. 

24.  Friedmann.     Virch.  Arch.  Bd.  181,  1905. 

25.  V.  Behring.     Therap.  d.  Gegenwart,  1907. 

26.  Koch,  Masur,  and  Kochel.    Beitx-.  z.  path.  Anat.  Bd.  16,  1894. 

27.  AucLAiR.     Re\Tie  de  la  tuberculose,  1898. 

28.  Koch.     Zentrld.  f.  Bakt.,  1890.     Deutscb.  med.  Woch.,  1891. 

29.  Sahli.     Basel,  1913. 

30.  Koch.     Deutsch.  med.  Woch.  14,  1897. 

31.  RuPPEL.     Lancet,  March  28,  1908. 

32.  Beraneck:.     Compt.  ren  d  I'acad.  des  sci.,  1903. 

33.  Sahli.     Correspbl.  f.  Sebweizer  Aertzte,  1906. 

34.  Klebs.     Zentrbl.  f.  Bakt.,  1896.     Deutsch.  med.  Woch.,  1907. 

35.  Spengler.     Deutsch.  med.  Woch.  xxxi,  1904,  xxxi  and  xxxiv,  1905. 

36.  Rosenbach.     Deutscb.  med.  Woch.,  1912,  No.  12. 

37.  V.  Baumgarten-.    Verhandl.  d.  path.  Gesel.,  1906. 

38.  V.  Pirquet.     In  Kraus-Levaditi  Handb.  d.  Immunforseh.  Bd.  i,  1908. 

39.  Mendel.    Med.  Klinik.,  1908. 


TUBERCULOSIS  475 

40.  MoRO.     Munch,  med.  Woch.,  1908. 

41.  "WoLF-EisxER.     Berlin  med.  GeselL,  May  15,  1907. 

42.  Calmette.     Acad.  des.  sci.,  June  17,  1907. 

43.  Cornet,     In  Xothnagel's  spez.  Path.,  etc.,  1907,  with  lit. 

44.  HiLDEBRAXD.     Deutsch.  Chir.,  1902,  complete  literature. 

45.  Pfeiffer  and  Friedberger.     Deutsch.  med.  Woch.,  1907. 

46.  Roger  et  Garxier.     Compt.  rend,  de  la  Soc.  de  bioiug.,  1900, 

47.  Huguexix.     Zentrbl.  f.  Bakt.  Orig.  Bd.  48,  1908. 

48.  ScHMORL  and  Geipel.     Miinch.  med.  Woch.,  1904. 

49.  Friedmaxx.     Virchow's  Arch.  Bd.  181,  1905. 

50.  Liebermeister.     See  Krabbel  Xo.  51. 

51.  Krabbel.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  120,  1913. 

52.  Brem.     See  Comet  and  Kossel  Xo.  12. 

53.  RiCKETTS.     Inf.  Immunit.,  etc.,  1911. 

54.  KOEXiG.     Chir.  Kon2:.  Yerh.  1,  1913. 

55.  F.  MuLLER.     20  Kong.  f.  inn.  Med.,  1902. 

56.  JOCHMAXX.     Yirch.  Arch.  Bd.  194,  1908. 

57.  E.  MuLLER.     Zentrb.  f.  Chir.,  1909. 

58.  E.  MuLLER.     Zentrbl.  f.  inn.  Med.,  1907. 

59.  CoRXET  und  Fraexkel.     Hvc.  Rundschau,  1907,  Xo.  15. 

60.  KoxiGSFELD.     Zeit.  f.  Bakt.' Orig.  Bd.  60,  1911. 

61.  V.  VoLKiiAXX',     Berlin,  klin.  Woch.,  18(5. 

62.  LoREXZ.     In  X^'otlmasel's  spez.  Path.,  etc.,  Wien,  1898, 
03.  Orth,     Berlin,  klin  Woch.,  1903. 

64.  V,  Baumgartex'.     Berlin,  klin.  Woch.,  1906. 

65.  JoRDAX.     Beitr.  z.  klin.  Chir.  Bd.  19,  1897. 

66.  Ziegler's  Lehrbuch  d.  Path.  Anat.,  Jena,  1910. 

67.  Falkexheim.     Zeitsch.  f.  klin.  Med.  Bd.  55  1904. 
08.  Lexer.     Arch.  f.  klin.  Chir.  Bd.  73,  1904. 

69.  Orth.     Same  as  Xo.  63. 

70.  Friedrich.     Deutsch.  Zeit.  f.  Chir.  Bd.  53.  1899. 

71.  HoxsELL,     Beitr.  z.  klin.  Chir.  Bd.  28,  1900. 

72.  Krause.     Deutsch.  Chir.,  1899,  with  lit. 

73.  Walderstrom.     Die  Tub.  d.  Coll.  fern.,  Stockholm,  1910. 

74.  Hexle.     Beitr.  z.  klin.  Chir.  Bd.  20,  1898,  with  lit. 

75.  Heile.     Zeitschr.  f.  klin.  Med.  Bd.  55.  1904. 

76.  JocHMAXX.     Yirc.  Arch.  Bd.,  194.  1908. 

77.  Batzxer.     Miinch.  med.  Woch.,  1908. 

78.  E.  Mt'LLER.     Same  as  Xo.  57. 

79.  SoHLER.     Miinch.  med.  Woch.,  1910. 

80.  E.  Beck.     Beitr.  z.  klin.  Chir.  Bd.  62,  1909. 

81.  RosEXBACH.     Berlin  klin.  Woch.,  1909. 

82.  Lexer.     Allg.  Chir.  i,  Stuttaart,  1914. 

83.  Braxdes.     Miinch.  med.  Woch.,  1912. 

84.  Wredex.     Zeit.  f.  Orth.  Chir.  Bd.  21.  1908. 

85.  Iselix.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  103.  1910. 

86.  DE  QuERVAix.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  114,  1912. 

87.  V.  Bruxs.     Chir.  kong.  Yerh.,  1894,  ii. 

88.  Bier.     Hyperaemia  als  Heilmittel.  Leipzig.  190G. 

89.  V.  BAUiiGARTEX"".     Miiuch.  med.  Woch.,  1906. 

90.  PoxcET  ET  Leriche.     Le  rheum,  tub..  Paris.  1909. 

91.  Melchior.    Zentrbl.  f .  Grenzgeb.,  1909,  with  lit.,  and  Berlin  klin.  Woch., 

1910,  No.  11. 


476  INFECTIONS  OF  WOUNDS 

92.  Maemorek.     See  Nos.  93  and  94. 

93.  HoHMEiER.     MiiBch.  med.  Woch.,  1908. 

94.  Kauemann,     Beitr.  z.  klinik.  d.  Tub.  Bd.  xi,  1908. 

95.  Bardenheuer.     Deutscb.  Zeit.  f.  Chir.  Bd.  112,  1911. 

96.  RoLLiER,     Die  Heliotberapie  d.  Tub.   (bei  chir.  rormen.),  Berlin,  1913 

97.  WiTTMER.     Deutseh.  Zeitsehr.  f.  CHir.  Bd.  114,  1912. 

98.  Franzoni.     Same  as  No.  97. 

99.  WiTTMER.    Beitr.  z.  klin.  Chir.  Bd.  33,  1902. 


CHAPTER  XXIV 


LEPROSY 


Leprosy  existed  in  Egj'pt  iu  prehistoric  times.  It  reached  Greece 
about  345  B.  C,  Italy  iu  the  first  ceutury  before  Christ,  and  from 
there  extended  over  Europe.  Leprosy  at  no  time  became  epidemic 
to  the  degree  that  obtained  in  connection  with  smallpox,  cholera, 
t3'phus,  etc.  In  1902,  tHe  United  States  Leprosy  Commission  found 
278  cases  in  this  country;  of  these,  186  probably  contracted  the  disease 
here;  120  of  the  patients  were  born  in  other  countries,  and  115  were 
native  born.     The  nationality  of  the  remaining  13  is  not  stated. 

The  contagiousness  of  the  disease  seems  to  have  been  recognized  at 

an  early  period.  In  636  A.  D. 
leprosy  houses  were  instituted 
and  the  segregation  of  pa- 
tients was  soon  established. 
AVhen,  in  the  sixteenth  cen- 
tury, the  disease  almost  dis- 
appeared, this  was  quite 
0f  (  )  y^n  *^^--^^y^  '^^  ]  )       properly  ascribed  to  the  strict 

\  r7^  r^^YO^  /^/SO''''      segregation  practiced  at  that 
).  ^OM/XL     y  i/DL^     .■„        time  (Ricketts^). 

The  Bacillus  Leprae. —  The 
bacillus  of  leprosy  was  first 
described  and  interpreted  as 
the  etiological  excitant  of  the  disease  by  G.  Amauer  Hansen^  (1879),  a 
Norwegian.  Hansen  found  the  bacillus  in  the  serous  exudate  and 
tissues  of  the  nodular  lesions  where  they  are  present  in  small  clumps, 
either  within  or  outside  the  cells.  Almost  simultaneously  Avith  Han- 
sen's publication,  Neisser^  reported  similar  results  obtained  by  him 
during  a  brief  stay  in  Bergen.  There  is  at  this  time  no  doubt  that 
the  bacillus  described  b}'  both  these  observers  is  the  cause  of  the 
various  forms  of  the  disease  known  aa  leprosy. 
The  leprosy  hacillus  is  a  small  rod  measuring  about  5-6  microns  in 

477 


Fig.   172. —  Lepra  Bacilli 


Xerve. 


478  INFECTIONS  OF  WOUNDS 

length,  and  bears  a  close  morphological  resemblance  to  the  tubercle 
bacillus ;  it  is,  however,  less  apt  to  display  the  beaded  appearance 
and  is  slightly  thicker  than  the  latter.  It  is  non-motile,  possesses  no 
flagella,  and  is  non-spore  forming. 

Like  tubercle  bacilli,  the  lepra  bacilli  belong  to  the  class  of  so-called 
acid  fast  bacteria,  being  stained  with  much  difficulty;  but  when  once 
stained  they  are  tenacious  of  the  color,  offering  considerable  resistance 
to  the  decolorizing  action  of  acids.  It  is,  however,  worthy  of  note 
that  the  difficulty  of  staining  and  the  resistance  to  decolorization  are 
less  marked  in  this  microorganism  than  in  the  bacillus  of  tuberculosis. 
This  is  of  diagnostic  value.  When  the  bacilli  are  stained  with  a  dilute 
(cold)  fuchsin  solution  (5  drops  of  saturated  alcoholic  solution  in  a 
watch  glass  full  of  w'ater)  from  six  to  seven  minutes,  decolorized  for 
fifteen  seconds  in  a  ten  per  cent  solution  of  saltpeter  in  alcohol, 
washed,  and  counter  stained  with  an  aqueous  solution  of  methjdene 
blue,  they  retain  the  red  color,  while  the  tubercle  bacilli  are  decolorized 
(v.  Baumgarten*). 

//(  cases  of  leprosy  the  hacillus  is  found  in  large  quantities  in  the 
proliferated  infiammatory  tissue  in  lesions  of  the  skin  and  mucous 
membranes,  in  the  nerves,  in  the  lymph  nodes,  and  in  the  internal 
organs.  They  have  also  been  found  in  spinal  ganglia,  in  the  spinal 
cord,  and  upan  the  surface  of  the  skin  and  mucosa  (Babes^).  During 
an  attack  of  fever  which  heralds  the  development  of  a  new  skin  node 
they  have  been  found  in  the  blood.  Sugai**  found  the  bacilli  in  the 
blood  of  a  new  born  infant. 

The  cultivation  of  the  leprosy  bacillus  has  not  met  with  definite 
results.  In  1909,  Clegg"  succeeded  in  growing  an  acid  fast  bacillus 
from  leprous  tissue,  obtaining  his  results  b}^  inoculating  leprous  mate- 
rial upon  agar  plates  upon  which  ameba  coli  had  been  grown  in 
sj'mbiosis  with  other  bacteria.  In  1912,  DuvaP  not  only  succeeded  in 
repeating  Clegg 's  experiment,  but  obtained  cultures  of  an  acid  fast 
bacillus  directly  from  leprous  lesions  without  the  aid  of  ameba.  In 
spite  of  extensive  work  upon  this  problem,  opinions  are  still  divided 
as  to  the  specific  nature  of  the  organisms  cultivated  by  Clegg  and 
Duval.  As  a  final  expression  of  the  present  conception  of  this  aspect 
of  the  situation,  it  is  proper  to  state  that  the  previous  reports,  together 
with  the  work  of  Kedrowski,"  who  made  similar  claims  in  this  connec- 
tion, have  not  been  verified  (Jadassohn^").  Sugai^^  reports  having 
successfully  inoculated  Japanese  dancing  mice.  Inoculation  of  the 
human  has  not  succeeded.    However,  direct  or  indirect  ircmsmission 


LEPROSY  479 

of  the  disease  is  certain,  though  the  danger  of  contagion  would  seem 
to  be  slight.  The  supposed  inheritance  of  the  disease  is  probably  due 
to  contagion  within  a  family. 

In  the  human  the  lepra  bacilli  enter  the  body,  probably  through 
the  skin  or  mucous  surfaces,  and  gain  access  to  the  lymph  and  blood 
channels,  and  are  thus  disseminated  in  the  form  of  a  chronic  inflam- 
matory process  which  is  attended  with  the  formation  of  vascular 
granulation  tissue.  This  granulation  tissue  appears  in  the  skin  in 
the  form  of  nodules  in  the  region  of  the  hair  follicles,  and  later  extends 
as  a  flat  infiltrate  or  may  form  additional  nodules.  In  the  nerve 
trunks,  the  connective  tissue  proliferation  is  spincUc-shapeel  and 
destroys  the  nerve  fibers.  These  tumor-like  enlargements  are  called 
lepromata.  The  bacilli  lie  in  large  clumps  within  and  between  the  cells 
and  may  (like  tubercle  bacilli)  be  found  within  poljTiuclear  giant  cells, 
so  that  a  drop  of  blood  taken  from  one  of  these  nodes  is  usually  found 
to  contain  the  organism.  These  conglomerate  collections  of  bacilli  are 
called  glolii  or  lepra  cells,  and  are  believed  to  consist  of  disintegrated 
cells  filled  with  bacilli  (Neisser,^  Hansen-).  Other  observers  regard 
them  as  clumps  of  bacilli  derived  from  the  lymphatic  vessels  (v.  Berg- 
mann^-).  The  lepromata  in  the  skin  may  ulcerate  and  at  times  be 
absorbed;  as  a  rule,  however,  they  do  not  undergo  any  appreciable 
change  after  being  once  fully  formed. 

The  period  of  incuhation  of  the  infection  may  extend  over  years. 
This  has  been  demonstrated  in  persons  who,  after  prolonged  residence 
in  a  leper  colony,  return  to  their  homes  and  later  develop  the  disease. 
The  primary  lesion  appears  in  from  three  to  five  years  after  exposure, 
though  instances  in  which  this  was  delayed  twentj^-seven  and  thirty- 
two  years  have  been  recorded. 

The  most  frequent  early  symptoms  of  leprosy  are  intense  sensations 
of  cold  in  the  hands  and  feet,  hyperesthesia  —  especially  of  the  legs  — 
and  the  appearance  all  over  the  body  of  erythematous  patches  which 
disappear  and  reappear  at  frequent  interv^als.  In  a  certain  number 
of  cases,  the  beginning  of  the  disease  is  characterized  by  a  flat,  dull 
brown,  slightly  elevated  infiltration  of  the  skin  several  centimeters  in 
width,  which  is  an  unfailing  forerunner  of  leprosy  in  its  two  forms, 
and  may  persist  for  years  before  the  disease  is  clearly  manifested. 
The  infection  may  invade  primarily  the  nasal  mucous  membrane^ 

Leprosy  appears  in  tivo  forms  which  merge  into  each  other,  the 
picture  varying  with  regard  to  the  dominance  of  skin  or  nerve 
involvement. 


480 


INFECTIONS  OF  "WOUNDS 


Leprosy  of  the  Skin. —  Lepra  tuberosa  begins  with  the  appearance 
of  a  nodular  infiltrate  which,  in  part,  develops  at  the  site  of  the  pro- 
dromal transitory  spots  already  spoken  of.  The  appearance  of  the 
nodules  is,  as  a  rule,  attended  with  the  general  symptoms  of  fever 
indicating  the  presence  of  the  bacteria  in  the  blood  and  their  lodgment 
in  the  skin.  Usually  the  disease  appears  first  upon  the  skin  of  the 
face  and  hands  in  the  form  of  reddish  brown  patches  and  areas  of 
pigmented  infiltration  which  coalesce  and  develop  into  round,  soft, 
red  or  blue  nodes,  or  into  broad  fi())ior-like  siceUings.  As  the  disease 
progresses  new  lesions 
develop,  the  occurrence 
of  which  is  attended 
with  the  sequence  of 
events  just  recorded ; 
finally,  the  entire  sur- 
face of  the  body  may 
become  involved.  The 
disease  usually  is  most 
active  on  the  skin  of  the 
face,  where  the  hair  of 
the  head,  eyetrows,  and 
eyelids  disappears,  and 
the  forehead,  the  nose, 
the  cheeks,  and  the 
auricles  are  heavih'  in- 
filtrated with  nodular 
deposits  giving  to  the 
patient  the  peculiar  ex- 
pression designated  as 
satyriasis  and  leontiasis. 
The  largest  nodes  form 

at  the  nose,  in  the  region  of  the  eyebrows,  and  at  the  lips,  so  that  the 
normal  apertures  in  these  locations  become,  at  times,  almost  invisible. 
These  lepromata  remain  for  a  long  time  without  undergoing  any 
alteration,  though  at  times  they  suddenly  enlarge,  break  down  and 
disappear. 

The  mucous  membranes  are  attackea  in  the  same  manner  as  is  the 
skin.  Simultaneously  with  the  latter,  the  mucous  membranes  of  the 
ej^eballs,  nose,  mouth,  and  pharynx  are  the  site  of  infiltration  and 
ulceration.     In  the  eye,  the  disease  gives  rise  to  iritis  and  keratitis; 


Fig.  173. —  Lepra  Tuberosa   (Pusey). 


LEPROSY  481 

in  the  larynx,  the  nodular  deposits  and  connective  tissue  infiltration 
stand  in  a  causative  relationship  to  the  classic  vox  rauca  leprosa  and, 
at  times,  produce  stenosis  which  endanger  life  by  strangulation. 

When  lepronuita  persists  for  a  long  time  in  the  mucosa,  the}-, like  those 
of  the  skin,  break  down  and  ulcerate.  The  lymph  nodes  contiguous 
to  a  local  lesion  are  almost  invariably  swollen  and  may  reach  a  large 
size.  According  to  de  la  Camp/^  the  deposit  of  the  bacilli  of  leprosy 
in  the  long  hones  is  followed  by  chronic  proliferative  periostitis  which 
causes  a  peculiar  spindle  shaped  thickening  of  the  bone. 

The  course  of  the  disease  is  exceedingly  variable.  In  one  class  of 
cases  the  process  is  mild  and  restricts  itself  to  a  single  group  of  nodes ; 
in  another,  additional  areas  are  attacked  at  short  intervals  in  the  form 
of  rapidly  growing  nodules  and  ulcerations;  in  a  third,  the  infection 
attacks  the  nerve  trunks  very  early  in  the  disease.  Death  occurs  in 
from  five  to  nine  years,  either  from  leprous  or  amyloid  degeneration 
of  the  vital  organs.  The  lungs  are  most  often  the  seat  of  the  fatal 
form  of  the  disease,  though,  in  this  location,  it  is  frequently  compli- 
cated by  tuberculosis. 

Leprosy  of  the  Nerves  {lepra  nervorum,  lepra  maculo-anesthetica) . — 
Leprosy  of  the  nerves  consists  of  a  leprous  tissue  proliferation  ushered 
in  by  the  appearance  of  a  fiat,  hrown  infiltration  in  the  skin  which  is 
not  attended  with  general  symptoms.  The  spots  are  slightly  elevated 
and  surrounded  by  a  pigmented  ring  which  gradually  extends,  while 
the  center  of  the  patch  blanches  and  loses  its  hairs  as  the  result  of 
atrophy  of  the  skin.  These  areas  become  anesthetic,  thus  giving  the 
first  evidence  of  nerve  involvement.  They  are  classified,  in  accord 
with  the  color  of  their  pigmentation,  as  black  or  white  leprosy 
(morphea),  and  at  times  extend  over  large  areas  of  the  body,  giving 
the  skin  the  appearance  of  a  map.  According  to  v.  Bergmann,^^  these 
flat  areas  of  infiltration  never  contain  the  bacilli  of  leprosy;  Babes^ 
claims  to  have  found  them  in  this  situation,  but  adds  that  they  are 
few  and  hard  to  find. 

The  nerve  lesions  usually  appear  first  in  the  areas  of  distribution  of 
the  ulnar,  median,  peroneal,  and  facial  nerves  in  which  sensory  impair- 
ment is  primarily  manifested,  and,  later,  the  sciatic  and  anterior  crural 
nerves,  the  spiral  ganglia,  and  the  gasserian  ganglion  are  also 
involved.  The  bacilli  have  been  found  in  the  spinal  cord  surrounded 
by  areas  of  infiltration.  In  accessible  locations,  an  affected  nerve  may 
be  palpated  as  a  thick  cord  U'ith  areas  of  spindle  shaped  thickening. 
As  the  nerve  fibers  are  destroyed  by  the  disease,  the  zones  they  supply 


482  INFECTIONS  OF  WOUNDS 

become  anesthetic  and  evince  trophic  disturhaiices :  1.  Atrophy  and 
paralysis  of  groups  of  muscles,  especially  those  of  the  thenar  and 
hypothenar  eminences,  also  the  interossei  muscles  and  those  of  the 
ulnar  side  of  the  forearm,  the  anterior  tibial  group,  and  the  muscles 
supplied  by  the  seventh  cranial  nerve.  2.  Contractures  of  the  fingers 
(most  frequently  the  fourth  and  fifth)  and  toes,  and  of  the  forearm 
and  leg.  3.  Pressure  ulcerations  which  are  circular  in  outline  and 
appear  in  the  sole  of  the  foot  beneath  the  os  calcis  or  at  the  head  of  a 
metatarsal  bone.  4.  Mutilation  of  the  fingers  and  toes  (lepra 
7nutilans),  the  result  of  necrosis  and  ulceration  of  the  phalanges. 
This  progressive  tissue  destruction  may  involve  fingers  or  toes,  or  may 
result  in  the  loss  of  an  entire  hand  or  foot.  At  times  the  process  is 
limited  to  insular  areas  of  granulation  tissue  proliferation  in  indi- 
vidual phalanges.  5,  The  formation  of  hlels  (pemphigus  leprosus) 
on  the  extremities  which  are  attended  with  fever  and,  after  breaking 
down,  leave  large,  obstinately  progressive  ulcers  which  may  persist 
for  years. 

Ultimately,  nerve  leprosy  also  leads  to  the  development  of  cachexia, 
and  death  follows  from  exhaustion. 

In  locations  where  leprosy  is  not  endemic,  it  may  escape  recognition 
for  a  long  time.  Leprosy  mutilans  of  the  nerve  form  of  the  disease 
presents  a  clinical  picture  not  unlike  that  of  syringomyelia,  as  the 
latter  is  also  attended  with  mutilation  of  the  fingers,  loss  of  sensation, 
and  atropli}^,  but  it  is  not  accompanied  by  palpable  evidence  of  con- 
nective tissue  proliferation  in  the  trunks  of  the  nerves.  The  brown 
or  red  patches  of  leprosy  are  not  alwaj^s  readily  differentiated  from 
syphilitic  exanthema.  In  all  doubtful  cases,  microscopical  examina- 
tion of  the  nasal  secretions  should  be  made. 

In  the  treatment  of  leprosy,  nursing,  nourishment,  and  cleanliness 
are  the  most  important  factors.  Isolation  of  the  afflicted  is  essential. 
The  larger  nodes  may  be  removed  u'ith  the  Tinife  or  destroyed  ivith  the 
actual  cautery.  When  the  process  in  the  fingers  and  toes  is  progres- 
sive, amputation  or  disarticulation  may  be  resorted  to.  Tracheotomy 
for  relief  in  connection  with  laryngeal  stenosis  may  be  necessary. 
Leprous  ulcers  are  kept  covered  with  antiseptic  dressings.  The 
administration  of  sodium  salicylate  is  advised  b}'-  Danielson.^'*  V. 
Bergmann^-  advises  giving  five  drops  of  gurjun  balsam  daily,  and  also 
that  the  same  remed3^,  mixed  with  lanolin,  be  applied  to  ulcers  once 
daily.     The  administration  of  iodin  and  mercury,  and  the  injection  of 


LEPROSY  483 

salvarsan,   diphtheria  serum,  and   tuberculin  have  not  been  found 
beneficial. 

BIBLIOGRAPHY 

1.  RiCKETTS.     Inf.  and  Immun.,  Chicago,  III.,  1911. 

2.  Hansen.     Vircbow's  Arch.,  79,  1879. 

3.  Neisser.     Breslauei-  iirtztl.  Zeitschr.,  20,  1879. 

4.  V.  Baumgarten.     Quoted  by  Jadassohn,  No.  10. 

5.  Babes.     Zentrbl.  f.  Bakt.  Ori^.  Bd.  59,  1911. 

6.  SUGAI.     Ref.  in  Zentrbl.  f.  Bakt.  Ref.  Bd.  50,  1911. 

7.  Clegg.     Philippine  Jr.  of  Sci.  iv,  1909. 

8.  Duval.     Jr.  Exper.  Med.  xii,  1910,  and  ibid  xv,  1912. 

9.  Kedrowski.     Zeitschr.  f.  Hyg.  Bd.  66,  1910. 

10.  Jadassohn.     In  Ivolle-Wassennann  Handb.  d.  jjath.  Microorg.  Aufl.  2, 

Bd.  5, 1913. 

11.  SuGAi.     Lepra,  B.  8 ;  f asc.  3,  1909. 

12.  V.  Bergmann.     Deutsch.  Chir.,  1897,  with  lit. 

13.  de  la  Camp.     Fortschr.  a.  d.  Gebiete.  d.  Rontgenstrahlen,  Bd.  4. 

14.  Danielson.     Quoted  by  v.  Bergmann  No.  12. 


CHAPTER  XXV 
SYPHILIS 

Syphilis  (lues)  is  a  chronic  infectious  disease.  Its  causative  factor 
is  a  microorg-anism  discovered  by  Schaudinn^  (1905)  in  the  exudate 
of  a  syphilitic  lymph  node,  and  because  of  its  delicate  structure  and 
spiral  form  designated  by  him  and  E.  Hoffman^  (a  collaborator) 
as  the  spirocheta  pallida.  The  spirocheta  pallida  (Fig.  174)  is  an 
extremely  delicate,  undulating  filament,  measuring  from  four  to  ten 
microns  in  length,  with  an  average  of  seven  microns,  and  varying  in 
thickness  from  an  immeasurable  delicacy  to  0.5  micron.  It  is,  there- 
fore, smaller  and  more  delicate  than  the  excitant  of  relapsing  fever. 
Examined  in  fresh  preparations,  it  is  distinctly  motile,  its  movements 
consisting  of  rotation  round  its  long  axis  and  gliding  movements  back- 
ward and  forward.  Its  convolutions,  as  counted  by  Schaudiun,  vary 
from  three  to  twelve,  and  differ  from  those  observed  in  many  other 
spirochetes  by  the  obtuse  angle  of  their  arrangement.  The  ends  of 
the  organism  are  tapered  and  possess  a  delicate  flagellum. 

The  discovery  of  Schaudinn  and  Hoffmann^  was  soon  confirmed  by 
many  observers,  and  the  etiological  relationship  of  the  spirocheta 
pallida  to  sjiDhilis  may  now  be  regarded  as  an  accepted  fact.  Although 
the  difficulty  in  cultivating  the  organism  has  made  it  impossible  to 
carry  out  the  postulates  of  Koch,  nevertheless,  indirect  evidence  of 
such  convincing  nature  has  accumulated  that  no  reasonable  doubt  as 
to  its  causative  bearing  can  be  retained.  Soon  after  Schaudinn 
reported  his  discover}^,  Sobernheim  and  Tomasczewski,^  Spitzer,^  and 
Mulzer*  recorded  a  convincing  series  ©f  positive  findings.  The  pres- 
ence of  the  spirochetes  in  the  Mood  at  certain  stages  of  the  disease 
was  demonstrated  by  Bandi  and  Simonelli'^  who  found  them  in  the 
blood  taken  from  roseola  spots,  and  by  Levaditi  and  Petresco^  who 
obtained  them  from  blebs  produced  upon  the  skin. 

In  tertiary  lesions  the  spirochetes  have  been  found  less  frequently 
than  in  the  primary  and  secondary  lesions,  but  positive  evidence  of 
their  presence  has  been  submitted  by  Tomasczewski;^  by  Ewing,^  and 

484 


SYPHILIS 


485 


by  Doutrelepont  and  Grouven,^  all  of  whom  found  them  in  gummata. 
Noguchi  and  Moore^^  found  the  spirochcta  pallida  in  the  hrain  of 
paretics.  Uhlenhuth  and  Mulzer's"  inoculations  into  rabbits  were 
followed  by  severe  forms  of  the  disease.  The  organism  has  been 
cultivated  on  horse  serum  by  Miihlens^-  and  by  Schereschewsky.^^ 

Staining  of  the  spirochcta  pallida  with  the  weaker  aniliu  dyes  is 
not  successful,  and  even  the  more  powerful  ones,  such  as  earbol  fuchsin 
and  gentian  \aolet  give  unsatisfactory  results.     For  the  purpose,  the 

original  stain  of 
Schaudinn  and  Hoff- 
mann^ is  still  largely 
used.  Its  action  de- 
pends upon  the  use 
of  Giemsa's  azur 
eosin  stain.* 

The  course  of  the 
disease  and  its  ex- 
traordinarily varied 
manifestations  have 
led  to  the  publica- 
tion of  special  works 
devoted  to  the  sub- 
ject. However,  the 
surgical  importance 
of  syphilis  lies  in 
the  resemblance  it 
bears  to  other  dis- 
eases, and  the  indi- 
cations it  often  pre- 


FiG.  174. —  Spirochetae  Pallidae  ix  the  Cornea  of  a 
Eabbit.  (Published  through  the  courtesy  of  Professor 
Hoffman.)       (Pusey.) 


sents  for  the  emplo^Tnent  of  operative  measures  of  relief. 

The  primary  lesion  {initial  chancre,  Hunterian  induratio7i,  hard 
chancre)  is  the  first  tissue  alteration;  it  heralds  the  onset  of  the 
infection  and  appears  at  the  port  of  entrance  of  the  excitants  of 
syphilis.  This  occurs  at  the  site  of  a  wound,  of  rhagades,  or  at  an 
ulceration  of  a  mucous  membrane  or  the  skin  as  the  result  of  direct 
or  indirect  contact  with  the  infectious  secretions  of  an  ulcerating 
chancre  or  moist  papule,  an  ulcer  of  the  skin  or  mucosa,  either  during 

*A  complete  list  of  staining  mixtures  for  the  recognition  of  the  spirocheta  in 
smears  and  in  tissues  may  be  found  in  Hiss  and  Zinsser's  "Textbook  of  Bacteri- 
ology," D.  Appleton  and  Co.,  Xew  York,  1916. 


486 


INFECTIONS  OF  WOUNDS 


the  early  or  late  forms  of  the  disease.  By  indirect  conveyance  is 
meant  the  transmission  of  the  disease  by  persons  who  are  not  syphilitic 
(soiled  fingers,  etc.),  or  by  inanimate  objects,  such  as  drinking  glasses, 
table  ware,  cigar  tips,  etc.  As  a  rule  only  a  single  primary  lesion 
develops,  though  this  is  not  invariable. 

Extragenital  chancre,  which  may  develop  at  any  portion  of  the  body 
(Fig.  175),  occurs  most  frequently  upon  the  face  (lips,  nose,  ej'elids, 
tonsils,  and  tongue),  the  fingers,  and  the  mammary  nipple,  and  is  more 
likely  to  escape  recognition  than  is  the  lesion  situated  upon  the  external 
genitals  or  in  their  vicinity. 

After  a  period  of  inciibation  of  from  two  to  four  weeks,  an  infiltra- 
tion of  the  skin  or  mucosa  makes  its  appearance  at  the  site  of  the  port 
of  entrance  .of  the  infection.  AVhen  this  infiltration  involves  the 
deeper  tissue  it  is  called  a  chancre,  if  superficial,  the  term  papule  is 
used.  When  a  mixed 
infection  occurs,  an  in- 
flammatory infiltrate  ap- 
pears two  days  after  in- 
fection and  the  sclerotic 
induration  develops  at 
the  expiration  of  the 
usual  period  of  incuba- 
tion. 

The     initial     chancre     _  „      „  ^  ,_       . 

,      -  „         Fig.   175. —  Extragenital  Chancre    (Pusey). 

appears  m  the  lorm  oi  a 

round,  oval  or  flat  induration  the  size  of  a  twenty-five  cent  piece ;  it  is 
red  in  color,  sharply  defined  and  hard  to  the  touch.  The  papule  is  ele- 
vated and  about  the  size  of  a  pea.  When  the  epithelium  exfoliates,  the 
area  of  induration  is  covered  with  hard  crusts  which,  when  removed,  re- 
veal a  raw,  bleeding  surface ;  or,  when  the  secretion  does  not  crust,  the 
lesion  is  covered  with  fluid  exudate  {wet  papule,  eroded  chancre  of  the 
genitals,  anus  or  mouth).  Disintegration  of  the  infiltrate,  often  the 
result  of  meddlesome  manipulations,  is  followed  by  tlie  formation  of 
a  sloughing  ulcer  which  has  hard,  not  undermined,  edges  and  a  hard 
base  {ulcerating  chancre).  When  the  infiltrate  becomes  gangrenous, 
a  deep  phagadenous  putrid  ulcer  with  a  black  crust  is  formed. 

Recession  of  the  primary  lesion  is  slow,  requiring  several  weeks  or 
months.  The  induration  disappears  or,  when  ulceration  has  occurred, 
an  area  of  scar  tissue  remains. 

Histologically,  the  development  of  the  primary  lesion  is  attended 


SYPHILIS  487 

with  small,  round  celled  infiltration  and  connective  tissue  prolifera- 
tion. The  process  attacks  primarily  the  tissues  surrounding  the  blood 
vessels  and  ultimately  involves  the  entire  skin  or  mucous  membranes. 
In  the  papular  form,  the  papillary  bodies  of  the  skin  are  dominantly 
involved.  In  some  instances,  proliferation  of  the  cellular  elements  of 
the  walls  of  the  blood  vessels  causes  obliteration  of  their  lumen 
(endovascuUtis  obliterans  syphilitica)  which  is  followed  by  disintegra- 
tion of  the  infected  area  (ulceration). 

The  diagnosis  of  luetic  chancre,  aside  from  finding  the  spirochetes, 
rests  on  the  hardness  of  the  infiltrate.  Ulcerated  chancre  of  the  skin 
bears  some  resemblance  to  carcinoma  in  this  location ;  however,  disin- 
tegration of  chancre  occurs  earlier  than  in  carcinoma,  and  lymph 
nodes  are  much  more  rapidly  invaded  by  syphilis  than  by  malignant 
disease.  L^Tiiphangitis  does  not  occur  with  ulcerating  gumma  unless 
there  is  a  secondary  infection;  a  helpful  consideration  in  differentiat- 
ing it  from  carcinoma,  especially  when  the  lesion  involves  a  mucous 
membrane. 

The  treatment  of  the  primary  lesion  should  aim  to  destroy  the 
spirochetes;  however,  the  measures  (cauterization,  disinfection  with 
chemical  agents,  and  excision)  are  uncertain,  since  their  emplojonent 
is  executed  after  the  excitants  have  already  gained  access  to  the  lymph 
stream. 

The  indurated  area  may  be  covered  with  mercurial  plaster  or  oint- 
ment spread  upon  gauze.  The  general  treatment  should  be  begun  as 
soon  as  the  diagnosis  is  established;  it  should  not  be  delayed  until 
constitutional  evidence  of  the  disease  is  manifested. 

The  lymph  nodes  contiguous  to  the  primary  lesion  enlarge  slowly 
until  at  the  end  of  four  or  five  weeks  (one  or  two  weeks  after  the 
appearance  of  the  chancre)  they  are  the  size  of  a  cherry  or  English 
walnut.  They  are  hard,  painless,  movable  upon  each  other,  and  the 
skin  is  movable  aver  them  unless  mixed  infection  causes  their  inflam- 
matory adherence  to  surrounding  tissues.  Kecession  is  slow,  their 
enlargement  persisting  long  after  the  primary  lesion  has  healed,  so 
that  in  certain  regions  (inguinal)  they  may  be  readily  palpated 
arranged  in  rows  {syphilitic  rosary). 

Clinically,  syphilis  is  a  local  disease  until  the  lymph  nodes  are 
involved ;  at  the  end  of  a  second  period  of  incubation  of  several  weeks, 
their  involvement  is  followed  b}'  a  general  systemic  invasion  which  is 
manifested  by  the  appearance,  on  the  skin  and  mucous  membranes,  of 
various  lesions  {eruptive  stage).     This  stage  of  the  disease  is  attended 


488  INFECTIONS  OF  WOUNDS 

with  g-eueral  disturbances  consisting  of  pain  in  the  muscles  and  joints, 
headache,  malaise,  slight  fever,  and  the  swelling  of  all  the  palpable 
lymph  nodes  which  form  tumors  the  size  of  beans  (scleradenitis)  that 
may  persist  for  many  j'-ears. 

The  eruptive  manifestations  of  the  disease  recur  at  more  or  less  fre- 
quent intervals  (so-called  secondary  syphilids)  ;  they  appear  in  the 
form  of  a  macular,  papular  or  pustular  eruption  upon  the  skin  or 
mucous  membranes,  and,  together  with  modified  forms,  are  of  great 
diagnostic  significance.  In  hereditary  syphilis  which,  according  to 
Lesser,^*  is  attended  with  the  same  general  picture  as  the  original 
form,  the  eruptive  manifestations  take  on  all  the  characteristics 
mentioned. 

The  tertiary,  or  late,  manifestations  of  syphilis  appear  after  the 
lapse  of  variable  periods  of  time.  In  both  the  hereditary  and  the 
acquired  forms  they  may  follow  immediately  after  or  during  the  so- 
called  early  stages  {galloping  syphilis),  or  they  may  appear  after 
several  decades  during  which  there  was  no  evidence  of  the  disease 
(latent  period).  The  manifestations  of  the  late,  or  tertiary,  form 
may  be  differentiated  from  the  secondary,  or  early,  forms,  though 
they  often  coexist,  and  the  latter  frequently  merges  into  the  former. 
The  latter  form  of  lues  which,  in  contrast  to  the  less  destructive  ac- 
tivities of  the  early  stage,  is  attended  with  grave  tissue  changes  (Vir- 
chow^^)  and,  despite  the  widely  disseminated  notion  to  the  contrary, 
has  not  lost  its  contagiousness,  is  of  great  interest  to  the  surgeon. 

Gumma  (gummatous  tumor,  syphiloma,  nodular  syphilid)  is  the 
characteristic  lesion  of  late  syphilis.  It  is  a  granulation  tumor  (Yir- 
chow")  which  possesses  the  peculiarity  of  appearing  either  singl}^  or 
in  groups  in  every  part,  organ,  and  tissue  of  the  body.  It  slowly 
grows  to  the  size  of  a  walnut  or  fist,  and  displaces  or  infiltrates  the 
parenchj^ma  of  the  organ  it  invades  by  proliferation  of  granulation 
tissue  rich  in  cellular  elements  and  newly  formed  blood  vessels.  "When 
recession  of  the  granulomatous  tumor  occurs,  the  iuA^aded  tissue  is 
either  destroyed  or  converted  into  scar  tissue. 

On  section,  a  fresh  gumma  presents  a  gray  or  grayish  red  translu- 
cent or  gelatinous  (soft  form)  surface.  The  tendency  to  disintegrate, 
shown  by  syphilitic  new  growths,  is  no  doubt  due  to  the  inflammatory 
changes  which  take  place  in  the  blood  vessels  supplying  them  (vascu- 
litis and  perivasculitis  syphilitica)  causing  obliteration  of  their  lumen. 
The  center  of  the  tumor  is  converted  into  an  opaque  yellow  area,  or 
several  insular  portions  of  the  gumma  simultaneously  undergo  a  sira- 


SYPHILIS  489 

ilar  change  and  ultimately  the  entire  tumor  oeconies  gangrenous.  In 
the  meantime,  a  rapid  proliferation  of  connective  tissue  takes  place 
in  the  surrounding  tissue,  forming  a  dense  capsule  which  sends  out 
trabeculae  into  the  gumma  itself. 

The  ultimate  fate  of  a  gumma  depends  upon  the  form  of  necrosis 
its  tissues  undergo.  When  it  is  converted  into  a  hard,  firm  mass,  the 
result  of  caseation  and  coagulation  necrosis,  or  when  fatty  degenera- 
tion occurs  (leaving  small  degenerated  particles  of  tissue),  the  gumma 
may  entirely  disappear  or  its  residue  become  encapsulated.  "When, 
however,  liquefaction  of  the  necrotic  tissue  occurs,  the  gumma  is  con- 
verted into  a  cheesy  fluid  mixed  with  small  particles  of  detritus,  and 
takes  on  the  form  of  an  abscess  or,  as  the  result  of  destruction  of  the 
overlying  skin  or  mucous  membrane,  an  ulcer  is  formed. 

The  gummatous  nicer  (ulcus  gummosum)  (Fig.  176)  usually  pre- 
sents more  or  less  characteristic  landmarks.  It  has  a  tendency-  to 
assume  a  circular  form,  and  has  steep,  sharply  defined  (not  under- 
mined) edges  surrounding  a  craterlike  base  consisting  of  yellowish 
gray  necrotic  tissue  which  is  either  dry  or  covered  with  a  purulent 
exudate.  The  ulcer  extends  deeply  into  the  hard  granulation  tissue 
of  the  gumma  and  is,  therefore,  surrounded  by  an  elevated  border 
until  the  progressive  destruction  of  the  tissues  reaches  the  peripheral 
skin  level.  "When  the  entire  disintegrating  mass  is  destroyed  and 
there  is  no  longer  any  deposit  of  new  tissue  at  the  edges  of  the  ulcer, 
healthy  granulations  make  their  appearance,  and  cicatrization  takes 
place.  The  ulcerations  extend  in  peculiar  forms;  one  side  may  heal 
while  the  other  is  still  ulcerating,  causing  the  lesion  to  take  on 
irregular  outlines  described  as  kidney  or  sickle  shaped.  When  several 
ulcers  coalesce,  and  the  center  heals,  the  process  often  takes  on  a  form 
designated  as  serpiginous. 

Microscopically,  a  gumma  consists  of  richh'  cellular  granulation 
tissue  in  which  a  few  epltheloid  and  an  occasional  giant  cell  may  be 
found.  The  blood  vessels,  in  contradistinction  to  tubercle,  are  abund- 
ant. The  walls  of  the  blood  vessels,  and  the  tissues  surrounding  them, 
are  thickly  infiltrated  with  proliferated  cellular  elements  (vasculitis 
and  perivasculitis  syphilitica). 

When  central  necrosis  of  a  gumma  is  established,  it  may  be  described 
as  consisting  of,  first,  a  central  cheesy  or  fatty  mass ;  second,  a  zone 
of  spindle  shaped  fibrous  connective  tissue  cells  and  a  moderate  amount 
of  epithelioid  and  giant  cells ;  third,  an  outer  zone  of  cellular,  vascular, 
proliferating  connective  tissue. 


490  INFECTIONS  OF  WOUNDS 

Gumma  is  not  alwaj^s  easily  differentiated  from  tubercle  or  from 
small  celled  sarcoma.  The  microscopical  findings  in  the  blood  vessels 
are  regarded  as  elucidating  in  this  connection. 

In  diagnosticating  syphilitic  lesions  it  is  well  to  bear  in  mind  that 
frequent  miscarriages  are  often  due  to  lues  of  the  placenta  or  fetus. 
However,  the  mother  who  bears  the  infected  fetus  of  a  syphilitic  father 


Fig.    176. —  Gummatous    Ulcers    (Pusey). 

may  remain  unaffected  by  the  disease  even  though  she  nurses  the 
syphilitic  offspring,  while  a  wet  nurse  may  contract  the  disease  from 
the  luetic  infant.     This  observation,  made  by  Collis  in  1837  and  by 
Baumes  in  1840,  is  explained  on  the  basis  of  acquired  immiinity. 
There  are  certain,  almost  infallible,  signs  indicative  of  hereditary 


SYPHILIS  491 

syphilis  which  may  be  summarized  as  follows:  The  occurrence  of 
parenchymatous  keratitis;  the  presence  of  so-called  Hutchinson  teeth 
which  are  described  as  having  half-moon  notches  in  the  upper  central 
(permanent)  incisors,  although  this  deformity  also  attends  other  dis- 
eases that  are  accompanied  by  grave  disturbances  of  nutrition;  when 
these  are  supplemented  by  the  occurrence  of  deafness,  the  result  of 
disease  of  the  internal  ear,  the  somewhat  fanciful  triad  of  Hutchinson 
may  be  said  to  be  established.  The  presence  of  fine  linear  scars  radi- 
ating from  the  mouth,  the  outcome  of  healed  rhagades,  are  considered 
to  be  of  diagnostic  value. 

The  principle  of  complement  fixation,  discovered  by  Bordet  and 
Gengou^*'  (1901)  has  been  used  for  serodiagnostic  purposes  in  diseases 
in  which  the  excitant  is  unknown  or  cannot  be  cultivated.  For  the 
diagnosis  of  syphilis,  "VYassermann,  Neisser  and  Bruck^'  worked  out  a 
reaction  in  this  connection.  The  reaction  depends  upon  the  fact  that 
when  an  antigen,  i.  e.,  a  substance  capable  of  stimulating  the  forma- 
tion of  antrbodies,  is  mixed  with  its  inactivated  antiserum  in  the 
presence  of  complement,  the  complement  is  fixed  by  the  combined 
immune  body,  and  antigen  can  no  longer  be  found  free  in  the  mixture. 
If  such  a  mixture  is  allowed  to  stand  at  room  temperature  for  an  hour 
or  more,  and  to  it  is  then  added  an  emulsion  of  red  blood  cells  together 
with  inactivated  hemolytic  serum,  no  hemolysis  will  take  place,  since 
there  is  no  free  complement  to  complete  the  hemolytic  system.  If,  on 
the  other  hand,  the  original  mixture  contains  no  antibody  for  the 
antigen  used,  the  complement  is  not  fixed  and  is  available  for  the 
activation  of  the  hemolytic  serum  added  later. 

The  reaction  ttnis  depends  upon  the  fact  that  neither  antigen  alone,  nor 
amhoceptor  {antibody)  alone,  can  fix  the  complement,  hut  that  this  fixation 
is  carried  out  only  by  the  combination  of  antigen  plus  amboceptor. 

A  discussion  of  the  methods  of  preparing  antigen,  hemolytic  serum 
(containing  amboceptor),  the  complement,  the  sheep's  corpuscles,  and 
the  method  of  obtaining  blood  or  other  fluid  for  testing,  is  taken  up 
in  extenso  in  works  especially  devoted  to  the  subjects.  The  principle 
upon  which  the  test  is  based  has  been  considered  briefly  so  that  the 
clinician  may  form  a  notion  of  the  factors  which  may  weigh  for  or 
against  an  interpretation  of  the  value  of  the  test  as  applied  to  surgical 
problems. 

^\\Q  actual  test  for  antihody  in  a  suspected  serum  is  carried  out  in 
the  following  way:  In  a  test  tube  of  suitable  size,  2  units  of  the 
complement,  0.2  c.cm.  of  the  inactivated  suspected  serum,  and  antigen 


492  INFECTIONS  OF  WOUNDS 

in  quantity  determined  by  titration,  are  mixed  and  the  total  volume 
brought  up  to  3  e.cm.  with  normal  salt  solution.  This  mixture  is 
thoroughly  shaken  and  placed  for  one  hour  in  a  water  bath,  or  in  the 
incubator,  at  37.5°  C.  At  the  end  of  this  preliminary  incubation, 
there  is  added  1  c.cm.  of  a  5  per  cent  emulsion  of  sheep's  corpuscles, 
and  two  units  of  hemolytic  amboceptor  determined  by  a  titration  of 
the  inactivated  hemolytic  serum.  This  mixture  is  again  placed  at 
37.5 °C.  for  one  or  two  hours.     If  the  antibody  is  present  in  the 

SUSPECTED  SERUM,  NO  HEMOLYSIS  TAKES  PLACE;  IF  ABSENT,  HEMO- 
LYSIS IS  COMPLETE.  The  former  DENOTES  THE  PRESENCE  IN  THE 
SUSPECTED  serum  OF  SYPHILITIC  SUBSTANCE. 

Despite  the  fact  that  the  exact  explanation  of  the  action  of  the 
various  elements  employed  is  not  known,  the  test  (widely  known  as 
the  Wassermann  reaction)  is  a  valuable  one.  However,  the  execution 
of  the  required  technic  is  not  easy  and  is  liable  to  error.  The  facts 
that  positive  findings  occur  in  scarlatina,  tuberculosis,  tumors,  and,  at 
times,  after  narcosis  (Wolfsohn^*),  and  also  that  the  test  is  of  no  value 
in  lues  until  after  the  fifth  week  must  be  taken  into  account.  In  a 
given  case,  a  positive  finding  does  not  indicate  whether  this  is  due  to 
the  presence  of  syphilitic  virus  or  to  the  persistence  of  reactive  sub- 
stances. The  reaction  is  not  determining  with  respect  to  a  local 
process.  For  instance,  it  would  be  uUwise  to  declare  a  carcinoma  of 
the  tongue  or  an  osteosarcoma  a  gumma  simply  because  the  serum  of 
the  patient  gave  a  positive  Wassermann  reaction.  In  car'.cs  of  this  sort 
only  a  negative  finding  is  of  importance.  The  test  is  of  great  value 
in  determining  the  efficacy  of  treatment;  however,  a  negative  finding 
at  the  end  of  a  few  months  of  treatment  must  not  be  considered  as 
conclusive,  since  a  recurrence  of  the  disease  and  a  return  of  a  positive 
reaction  is  not  uncommon.  In  sj-philis  of  the  central  nervous  system, 
the  blood  often  gives  a  negative  result  when  the  fluid  withdrawn  by 
lumbar  puncture  is  positive.  The  latter  is  always  indicative  of  lues 
of  the  brain  and  spinal  cord. 

A.     SYPHILIS  OF  THE  SKIN 

The  late  manifestations  of  syphilis  of  the  skin  are  of  surgical 
importance. 

Gumma. —  Gumma  of  the  skin  appears  in  three  forms ;  the  nodular, 
the  cutaneous,  and  the  subcutaneous  infiltrate. 

In  the  first,  groups  of  hard,  reddish  hrown,  elevated  nodules  (the 


SYPHILIS  493 

size  of  a  lentil)  appear  on  the  skin,  while  the  nodules  located  in  the 
center  of  a  group  undergo  absorption,  ulceration,  and  cicatrization; 
new  nodules  develop  at  the  edge  of  the  lesion.  These  soon  coalesce 
into  a  narroiv  zone  of  infiltration  and  as  this  extends,  in  the  form  of  a 
how,  it  leaves  an  area  at  its  inner  aspect  which  is  concerned  in  the 
process  of  cicatrization  (papuloserpiginous  syphilid). 

At  times,  this  form  of  the  disease  is  confused  with  tuberculosis  of 
the  skin  (lupus),  as  both  the  nodules  and  the  sequential  ulcers  closely 
resemble  tuberculosis.  However,  lupus  is  much  slower  in  its  develop- 
ment and,  as  it  usually  recurs  in  old  scar  tissue  (healed  lupus),  it 
does  not  extend  from  the  periphery  of  the  lesion,  nor  does  it  take  on 
the  serpiginous  form  of  extension  common  in  lues. 

The  luetic  ulcer  of  the  skin  is  deep ;  its  base  is  covered  with  puru- 
lent exudate ;  and  it  has  deep  borders ;  that  of  lupus  is  flat,  slightly 
elevated,  and  covered  with  granulations. 

Gummatous  infdtrates  of  the  skin  are  round  (Fig.  176),  enlarge 
slowly  to  the  size  of  a  walnut  and,  early  in  the  process,  are  red  or  red- 
dish brown  in  color,  while  the  suhcutaneous  nodes  are  larger,  and,  at 
first,  covered  with  healthy  skin  to  which  the  process  gradually  extends. 
The  cutaneous  and  subcutaneous  nodes  are  rarely  single,  appearing 
usually  in  several  groups,  although  they  infrequently  involve  exten- 
sive areas  of  the  body.  They  are  most  often  located  upon  the  nose, 
the  forehead,  the  lips,  and  the  leg. 

In  part,  these  luetic  deposits  undergo  absorption  without  breaking 
down;  more  often,  they  form  gummatous  ulcers  which  heal  very 
slowly  with  the  formation  of  ivhite,  glistening  areas  of  scar  tissue,  or 
may  ulcerate  into  the  deeper  tissues  creating  severe  mutilations.  The 
latter  occur  frequently  upon  the  face  where  they  destroy  the  lips,  the 
entire  nose — including  the  cartilage  —  and  the  eyelids.  Extensive 
ulceration  may  convert  the  skin  of  the  head  and  forehead  into  a  large, 
glistening,  smooth,  immovable  scar  with  a  few  islands  of  nodular  skin. 
In  some  instances,  the  entire  face  is  a  mass  of  scar  tissue  radiating 
from  three  small  holes  that  correspond  to  the  mouth  and  the  nares. 
Occasionally,  carcinoma  develops  upon  a  persistent  luetic  ulcer. 

The  recognition  of  gummatous  skin  infiltration,  when  associated  with 
other  syphilitic  manifestations,  is  not  difficult,  especially  when  the 
lesion  appears  in  a  characteristic  form. 

The  rapid  development  and  the  blue  color  of  sarcoma  of  the  skin, 
and  the  acute  fever  and  pain  of  erythema  nodosum,  differentiate  these 
afflictions  from  slowly  growing  skin  gumma ;   however,  the  distinction 


494  INFECTIONS  OF  WOUNDS 

between  non-ulcerating  gumma  and.  the  tumors  of  mycosis  (or  the 
granuloma  fungoides)  is  not  so  easily  made. 

A  single  insular  gummatous  ulcer  bears  some  resemblance  to  carci- 
noma of  the  skin.  In  the  former  there  is  rarely  any  involvement  of 
the  contiguous  lymph  nodes,  and  when  they  become  enlarged,  as  a 
result  of  irritation  or  mixed  infection,  they  do  not  present  the  hard 
consistence  peculiar  to  malignant  disease.  The  base  of  a  carcinoma- 
tous skin  lesion  is  hard,  fissured,  bleeds  readily,  and,  at  times,  comedo 
like  plugs  may  be  expressed  from  its  base ;  per  contra,  the  base  of  a 
gummatous  ulcer  is  not  so  dense,  contains  necrotic  tissue  and  exudate, 
and  bleeds  only  at  places  where  reparative  granulations  have  formed. 

The  ulcers  and  areas  of  infiltration  of  chronic  malleus  of  the  skin 
may  be  recognized  by  microscopic  identification  of  the  excitants  (see 
malleus),  though  animal  inoculation  may  be  necessary.  Leprous  nodes 
and  ulcers  may  also  be  identified  by  the  presence  of  the  bacilli  in  tissue 
excised  for  the  purpose.  Actinomycotic  infiltrate  rarely  ulcerates  and 
bears  more  resemblance  to  tubercle,  though,  of  course,  the  presence  of 
the  fungi  in  the  pus  makes  the  diagnosis  certain. 

In  doubtful  cases,  the  result  of  antisyphilitic  treatment  may  he 
awaited;  however,  if  this  is  not  followed  hy  determining  improvement 
in  instatices  in  which  malignant  disease  is  suspected,  tJie  lesion  should 
be  excised  at  the  end  of  two  weeks. 

The  treatment  of  gummatous  nodules  and  ulcers  consists  of  energetic 
general  treatment.  The  local  application  of  mercury  ointments  and 
plasters  is  of  great  value.  The  curcttement  of  ulcers  and  the  free 
incision  of  indolent  nodules  and  removal  of  the  proliferated  tissue  are 
of  signal  benefit.  The  defects  and  deformities  consequent  to  cicatriza- 
tion may  be  made  the  objects  of  plastic  measures  of  correction. 

B.     SYPHILIS  or  MUCOUS  MEMBRAl^S 

Aside  from  the  primary  lesion  which  appears  upon  the  vermilion  of 
the  lip,  upon  the  tonsil,  the  gum,  or  the  tongue  in  the  form  of  a 
chancre  —  often  attended  with  considerable  lymphadenitis  of  the 
neck  —  the  early  lesions  of  syphilis  of  mucous  membranes  appear  in 
the  mouth  as  a  part  of  the  general  manifestations  accompanying  the 
exanthema  of  the  skin,  or  they  may  appear  as  a  recurrence  independ- 
ently of  the  latter.  In  the  mouth  these  lesions  take  on  the  form  of 
sharply  defined  erythematous  patches;  of  round,  flat,  pearl  gray,  or 
bluish    white    papules;     or    of    sloughing,    suppurating    ulcers    and 


SYPHILIS  495 

rhagades  which  correspond  to  the  luetic  patches,  papules,  and  ulcers 
of  the  skin. 

Ulcers  and  rhagades  appear  most  frequently  at  the  angle  of  the 
mouth,  papules  most  frequently  on  the  tongue,  and  a  form  of  the 
process  {angina  syphilitica)  is  found  on  the  soft  palate  and  pharynx. 
This  last  begins  with  redness  of  the  uvula  and  soft  palate,  and  forms 
a  lioiv  shaped  area  sharply  defined  against  the  contiguous  healthy 
mucosa.  It  is  readily  differentiated  from  non-specific  angina.  Not 
infrequently,  it  is  attended  with  painful  swelling  and  ulceration  of 
the  tonsil,  the  ulcers  being  covered  with  a  grayish  deposit  of  fibrin ; 
however,  the  absence  of  fever  and  the  presence  of  grayish  white, 
opalescent  papules  {plaques  opalines)  on  the  soft  palate  and  posterior 
phar}Tigeal  wall,  differentiate  the  disease  from  diphtheria. 

Gummatous  lesiojis  of  mucous  membranes  most  frequently  involve 
the  nasal  and  buccal  cavities,  the  larynx,  and  the  rectum.  As  the 
process  often  extends  to  cartilage  and  bone,  it  is  likely  to  be  attended 
with  extensive  loss  of  substance.  Perforation  of  the  soft  and  hard 
palate,  the  septum  and  the  nasal  bones,  deformation  of  the  soft  palate 
and  wall  of  the  pharjnix,  cicatricial  narrowing  of  the  larynx  (follow- 
ing gummatous  ulcer  of  the  arytenoid  cartilage  and  the  true  and  false 
vocal  cords),  and  of  the  rectum,  often  follow  this  form  of  the  disease. 
Involvement  of  the  nasal  mucous  membrane  is  attended  with  a  puru- 
lent, foul  smelling  discharge  (ozena),  which  is  followed  by  a  gradual 
sinking  of  the  nasal  bridge  due  to  destruction  of  the  bones  by  ostitis 
gummosa.  When  the  base  of  the  skull  is  invaded  from  the  nose,  fatal 
meningitis  is  likely  to  occur. 

The  diagnosis  of  gummatous  ulcers  of  mucous  membranes,  in  char- 
acteristic cases,  is  not  an  involved  problem.  On  the  tongue,  the  tumor 
form  of  gumma  (without  ulceration)  is  likely  to  be  mistaken  for 
carcinoma;  however,  gumma  does  not  cause  hard  lymph  node  swell- 
ings, which  is  the  rule  in  malignant  disease.  In  doubtful  cases  a 
section  of  the  growth  should  be  examined  microscopically.  Often  a 
carcinoma  of  the  tongue  is  subjected  to  prolonged  antisyphilitic  treat- 
ment ivith  the  i'esult  that  operative  removal  is  impossible. 

Tubercidous  ulcers  of  mucous  membranes  are  flat,  do  not  have  sharp 
borders,  their  edges  are  undermined  and  phagedenous,  their  bases 
granulating,  and  they  are  often  surrounded  by  miliary  tubercles. 

In  addition  to  the  general  treatment,  ulcers  of  the  nose  and  mouth 
may  be  frequently  lavaged  with  mild  antiseptic  solutions  (potassium 


496  INFECTIONS  OF  WOUNDS 

permanganate,  aluminum  acetate,  boric  acid,  etc.).     Liberal  adminis- 
tration of  potassium  is  indicat'^d, 

C.     SYPHILIS  OF  MUSCLES 

The  early  systemic  invasion  of  the  spirochetes  is  attended  with 
inuscle  pains  which  may  persist  for  a  year.  These  have  been  ascribed 
to  toxemia,  but  the  actual  cause  of  so-called  syphilitic  rheumatism  is 
not  known.  At  times  the  pain  is  attended  with  contractures  of 
muscles,  the  biceps  and  other  flexor  muscles  of  the  arm  being  most 
frequently  involved.  These  contractures  and  the  pain  gradually  dis- 
appear. Usually  syphilis  of  muscles  appears  in  the  form  of  myositis 
fibrosa  or  myositis  gummosa  (Virchow^''). 

Fibrous  Myositis. —  Diffuse  syphilitic,  or  fibrous,  myositis,  which 
usually  occurs  several  years  after  infection,  develops,  as  a  rule,  in  a 
single  muscle,  but  may  attack  several  muscles  simultaneously.  It 
invades  most  often  the  masscter  and  the  muscles  of  the  calf,  and  next, 
in  order  of  frequenc}^  the  arm,  the  sternomastoid,  and  the  sphincter 
ani.  The  entire  muscle  swells,  at  times,  acutely,  at  others,  slowly, 
and,  as  the  result  of  an  interstitial  inflammation,  becomes  hard  and 
painful  to  the  touch;  and  as  tension  increases,  causes  contractures 
{lockjaw,  wry  neck,  etc.),  and  loss  of  function. 

Microscopical  examination  shows  that  the  luetic  form  does  not 
differ  histologically  from  other  forms  of  myositis  (HonselP**  and  O. 
Busse^o) . 

Complete  healing  in  fresh  cases  usually  follows  energetic  antisyphil- 
itic  treatment  in  a  few  weeks.  In  other  instances  the  muscle  fibers 
are  destroyed,  and  the  entire  muscle  is  converted  into  a  contracted, 
thin  layer  of  connective  tissue,  especially  when  the  diffuse  infiltrate  is 
studded  with  small  gummatous  foci  {cicatricial  gumma). 

Gummatous  Myositis. —  Muscle  gumma  is  essentially  a  manifestation 
of  late  lues.  The  lesion  may  be  located  in  the  belly,  near  the  origin 
or  near  the  insertion  of  the  muscle  and  appears  as  a  circumscribed 
hard  node  which  at  times  is  of  considerable  size.  The  lesion  may  be 
single  or  multiple  in  the  same  muscle,  or  may  appear  in  several  muscles 
at  the  same  time.  Muscle  gumma  is  most  often  located  in  the  sterno- 
mastoid and  in  the  muscles  of  mastication.  Next  in  frequency  it 
appears  in  the  muscles  of  the  shoulder,  the  arm,  the  calf,  and  the 
gluteal  region  in  the  order  mentioned.  It  is  not  uncommon  in  the 
tongue. 


SYPHILIS  497 

The  onset  of  the  gumma  is  not  attended  with  symptoms  and  is 
usually  accidentally  discovered  when  the  gumma  reaches  a  certain 
size.  Trauma  is  believed  to  precipitate  its  development,  but  probably 
only  calls  attention  to  it.  Large  single  gummata  are  more  readily 
palpated  than  are  the  small  multiple  ones,  especiall}'  when  the  latter 
are  contained  in  a  diffusely  infiltrated  muscle.  Thej'  appear  larger 
when  the  muscle  is  contracted  than  when  it  is  relaxed,  and  are  movable 
with  the  muscle  until  they  become  attached  to  the  surrounding  tissues 
preliminary  to  disintegration  and  extension  to  the  surface.  When 
the  nodes  do  not  disappear,  and  leave  in  the  muscle  an  area  of  scar 
tissue  adherent  to  the  surrounding  parts,  they  break  down  into  an 
abscess  which  perforates  and  reaches  the  surface  of  the  body.  A 
process  of  this  sort  is  attended  with  the  formation  of  large  sloughing 
cavities  in  the  soft  parts — the  deep  gummatous  ulcer  —  which  ulti- 
mately heal,  but  not  until  large  portions  of  muscle  substance  have 
been  destroyed. 

Muscle  gumma,  before  it  breaks  down,  is  always  difficult  to  recog- 
nize, especiall}'  when  not  resident  in  one  of  its  favorite  resorts  such 
as  the  sternomastoid  muscle  or  the  tongue.  Small  nodules  resemble 
cysticercus  and  in  the  abdominal  muscles  are  readily  confused  with 
muscle  fibroma.  Rapidly  growing  gummata,  especially  when  they  are 
soft  and  become  attached  to  surrounding  tissues  (bones,  skin,  and 
blood  vessels),  bear  a  close  resemblance  to  soft  sarcomata.  Broken 
down  purulent  nodes  present  a  picture  similar  to  primary  and  second- 
ary muscle  tuberculosis  (especially  at  the  thorax)  ;  the  pus  of  a  luetic 
lesion  is  at  times  steel  blue  in  color  (v.  Bramann^^),  but  cannot  often 
be  differentiated  from  that  of  tuberculosis.  Diffuse,  hard  infiltration 
of  the  muscles  of  mastication  resembles  the  onset  of  actinomycosis  of 
the  face.  Abscesses  in  contact  with  large  blood  vessels  convey  the 
impulse  of  the  vessel  and  may  be  mistaken  for  aneurism.  Ulcerating 
gumma  of  the  tongue  is  most  likely  to  be  mistaken  for  the  flat,  slowly 
extending  form  of  carcinoma.  The  absence  of  the  characteristics  of 
cancer,  the  occasional  coalescence  of  several  nodules,  the  absence  of 
pain,  and  the  lessening  of  the  area  under  constitutional  treatment, 
may  justify  a  diagnosis  even  though  the  usual  distinguishing  land- 
marks are  absent. 

Intensive  antisyphilitic  treatment  is  often  followed  by  complete 
absorption  of  a  diffuse  muscle  infiltration.  However,  in  doubtful 
cases,  where  there  is  suspicion  of  malignant  disease,  medication  should 
not  be  carried  on  until  the  tumor  is  inoperable.     If  no  improvement 


498  INFECTIONS  OF  WOUNDS 

is  manifest  in  two  weeks,  operative  measures  of  relief  should  be 
employed.  Exploratory  incision  does  not  always  make  differentiation 
hetween  gumma  and  sarcoma  possible.  Microscopical  examination  is 
not  satisfactory  in  all  instances.  The  disclosure  of  giant  cells  with 
peripherally  arranged  nuclei  is  strongly  indicative  of  muscle  gumma 
(Landois^"). 

Wedge  shaped  removal  of  large  gummata  favors  post  operative 
repair.  Ulcers  should  be  subjected  to  the  application  of  mercurial 
preparations. 

D.     SYPHILLIS  OF  THE  LYMPH  VESSELS  AND  NODES  AND  OF 
THE  BLOOD  VESSELS 

Lues  of  lymph  vessels  is  not  of  great  importance.  The  initial  lesion 
on  the  penis  and  extragenital  infections  on  the  arm  and  face  are  at 
times  attended  with  red  streaks  and  long,  hard,  cords  denoting  lymph- 
angitis, which  soon  disappear  spontaneously. 

Syphilitic  Lymphadenitis. —  Syphilis  of  the  lymph  nodes,  though 
rare,  is  important,  because  of  the  likelihood  of  its  being  mistaken  for 
other  diseases. 

■  The  lymphatic  enlargement  contiguous  to  a  primary  lesion  and  the 
general  lymphatic  nodular  swelling  which  appear  coincident  with  the 
manifestations  of  the  secondary  stage  of  the  disease  already  described 
are  not  likely  to  fail  of  recognition. 

-Ij  On  the  other  hand,  gummatous  lymphadeyiitis  is  very  likely  to 
present  a  difficult  diagnostic  prohlem.  Gummatous  enlargement  of 
l;^Tnph  nodes,  especially  in  the  submaxillary  and  inguinal  regions, 
appears  in  the  form  of  hard,  nodular  tumors  which  slov/ly  increase  to 
the  size  of  a  hen's  egg  and  are  very  likely  to  be  mistaken  for  new 
growths  (for  instance,  of  the  submaxillary  salivary  gland)  or  for  hard 
tuhercidous  lymphadenitis.  When  the  process  becomes  adherent  to 
surrounding  tissues,  malignant  disease,  actinomycosis,  and  tubercu- 
losis of  lymph  nodes  must  be  taken  into  account.  When  the  gumma- 
tous glands  break  down  and  are  converted  into  deep,  sloughing  ulcers, 
the  diagnosis  is  easier.  Extensive  ulcerative  destruction  of  tissue,  at 
times  extends  to  large  blood  vessels,  giving  rise  to  fatal  bleeding 
(innominate  vein,  femoral  artery,  etc.,  v.  Esmarch^^). 

Gummatous  processes  of  this  sort  usually  slowly  recede  under  ener- 
getic antisyphilitic  treatment  Resection  of  the  glands  and  curette- 
'^'M'&nt'oi  broken  down  areas,  promote  healing. 


SYPHILIS  499 

Syphilis  of  the  Blood  Vessels. —  Syphilis  of  blood  vessels  appears  in 
the  late  stage  of  the  disease.  It  may  be  primary,  that  is  to  say,  inde- 
pendent of  a  syphilitic  lesion  of  surrounding  tissues,  and  may  involve 
the  arteries  in  the  form  of  a  proliferative  and  cellular  infiltration  of 
the  various  coats  of  the  vessel  with  a  tendency  toward  ohUteration 
{arteritis  syphilitica  obliterans)  in  which  the  smaller  arteries,  such  as 
the  basilar,  become  mere  fibrous  cords.  Although  specific  changes  in 
this  form  of  arteries  are  not  pecujiar  to  themselves,  they  can  still  be 
differentiated  from  arteriosclerosis,  as  the  former  usually  attacks  young 
persons,  is  likely  to  be  restricted  to  certain  areas  of  the  body  (espe- 
cially in  the  area  of  distribution  of  the  internal  carotid),  is  attended 
with  much  thickening,  and  is  not  accompanied  by  either  fatty  or 
calcareous  degeneration. 

Or  the  process  may  occur  in  connection  with  a  gummatous  lesion 
which  surrounds  arteries  and  veins.  In  these  instances  the  histological 
changes  are  similar  to  those  attendant  upon  the  primary  form  of  the 
disease.  The  blood  vessels  break  down  with  the  gumma  and,  in  rare 
instances,  a  small  gummatous  deposit  occurs  in  the  wall  of  an  artery. 

E.     SYPHILIS  OF  BONE. 

The  important  luetic  bone  lesion  is  gummatous  in  character  and  is 
located  in  the  periosteum,  the  medulla  of  the  hone,  or  extends  to  the 
bone  from  contiguous  tissues.  Syphilis  as  a  rule  attacks  the  bone  late 
in  the  disease;  however,  in  virulent  types  of  the  infection,  it  may 
occur  during  the  eruptive  stage,  in  which  event  it  usually  involves  the 
periosteum  to  only  a  moderate  extent.  Trauma  may  be  said  to  have 
little  to  do  with  this  form  of  the  disease  so  far  as  causation  is 
concerned. 

Irrespective  of  whether  luetic  invasion  of  bone  is  developing,  or 
disintegration  or  suppuration  is  taking  place,  it  is  always  attended 
with  two  processes:  Wherever  the  gummatous  granulations  prolif- 
erate into  the  bone  tissue  it  destroys  it  either  b.v  ulceration  (caries) 
or  by  necrosis,  and  at  the  same  time  irritates  the  surrounding  bone 
tissue  into  the  formation  of  new  hone;  therefore,  the  more  active  the 
process  of  destruction,  the  more  7nassive  is  the  outline  of  the  hone. 
In  the  diffuse  form  of  the  disease,  the  picture  presented  by  the 
osteophytes  and  partial  hyperostosis  is  either  that  of  a  hyperostosis  of 
the  entire  bone  with  thickening  of  its  tissues  (osteosclerosis,  ehurna- 
tion),  or  the  bone  undergoes  rarefication  as  the  result  of  absorption 


500  INFECTIONS  OF  WOUNDS 

(osteoporosis)    and   a   consequent   abnormal   friability   is   developed 
(osteopsathyrosis) . 

Luetic  Periostitis. —  Circumscribed  luetic  periostitis,  or  gumma,  in 
the  hereditary  and  acquired  forms  of  the  disease,  occurs  most  often 


'j?*>i 


i  • 


a 


•*t^' 


■If 


t 


b 


Fig.  177. —  Syphilitic  Hyperostosis  of  the  Tibia. 

a,  Roughened  surface  of  the  bone  covered  with  osteophytes; 
6,  longitudinal  section  of  the  bone.  Medullary  cavity  obliterated. 
In  the  center  osteosclerosis,  above  and  below  osteoporosis. 

during  the  eruptive  stage.     As  a  rule,  it  appears  simultaneously  in  the 
frontal  and  parietal  hones,  also  in  the  sternum,  clavicle,  etc.     Its  devel- 


SYPHILIS 


501 


opment  is  rapid  and  very  painful,  and  is  manifested  in  the  form  of 
fiat,  elastic  protuberances,  the  size  and  shape  of  a  watch  glass,  which 
are  usually  covered  by  normal  skin.  In  instances  in  which  the  lesions 
are  extensive,  the  overlying  skin  may  be  slighth'  reddened  and  edema- 
tous. Incision  (which  is  objectionable)  liberates  a  tenacious,  sticky 
fluid.  The  gummatous  proliferation  of  this  form  of  the  infection  is 
moderate  in  degree,  and  consists  only  of  a  gelatinous  infiltration 
originating  from  the  inner  layer  of  the  periosteum,  from  which,  at 
times,  small  projections  extend  into  the  Haversian  canals  of  the  bone. 
Many  observers  regard  this  form  of  periostitis,  which  attends  the 

early  stage  of  syphilis,  as  similar  to 
the  periosteal  gumma  of  the  later 
stages,  the  difference  b'iug  only  in 
the  extent  of  the  lesion. 

As  the  infiltration  of  early  luetic 
periostitis  is  slight  and  soon  dis- 
appears without  the  occurrence  of 
disintegration  or  suppuration,  it  is 
not  followed  by  marked  changes  in 
the  conformation  of  the  bone.  Its 
visitation  is  evidenced  by  slight  tran- 
sient depressions  in  the  bone,  the  re- 
sult of  caries  sicca  which,  as  a  rule, 
ultimately  disappear. 

In  the  late  stages  of  lues,  the  de- 
FiG.     178. —  ExTEXsm;     Ulceration       i  j.      c  •     ^     7 

FOLLOWING    Breaking    Down    op  ^elopment   of   periosteal   gumma   is 

Large    Periosteal    Gummata    of  characterized    by    its    gradual    and 

THE  Frontal  and  Parietal  Bones.  •  .      .  iV       t^.       •    •      ^       • 

ixir,  J.  uw      u  persistent  growth.     It  originates  m 

the  inner  layers  of  the  periosteum  and  penetrates  the  bone  along  the 
course  of  the  blood  vessels.  Flat,  circumscrihed,  slightly  elevated,  and 
not  very  painful  protrusions  (tophi)  appear  simultaneously  in  several 
regions  of  the  body,  especially  on  the  anterior  half  of  the  skull,  the  shin 
bones,  the  rihs,  the  sternum,  the  clavicle,  and  the  tones  of  the  foret 
arm;  they  vary  in  size  from  that  of  a  silver  dollar  to  that  of  the  adult 
fist. 

At  first  the  lesions  are  elastic  to  the  touch  and  are  covered  with 
normal  skin,  but  they  soon  undergo  regressive  changes.  Cheesy  or 
fatty  degeneration  is  followed  by  absorption,  or  suppuration  super- 
venes. In  the  first  instance,  the  dome  of  the  protrusion  gradually  col- 
lapses and  the  gumma  is  absorbed  without  breaking  down,  leaving  at 


502 


INFECTIONS  OF  WOUNDS 


the  site'  of  the  healed  lesion  a  more  or  less  deep,  crater-like  indention 
surrounded  by  a  wall  of  hard  bony  tissue — the  outcome  of  ossifying 
inflammation. 

When  suppuration  occurs,  the  gumma  gradually  softens,  fluctuation 
develops,  the  overlying  skin  thins  and  becomes  red,  and,  if  egress  for 
the  fluid  mass  is  not  provided  by  aspiration  or  incision,  the  soft  parts 
rupture  and  extensive  ulceration  follows.     The  edges  of  the  ulcer  thus 
formed  are  loosened  by  the  progressive  destruction  of  the  underlying 
parts,  attended  with  extensive  sloughing  and  the  discharge  of  slimy, 
foul  smelling  pus  mixed  with  shreds  of  disintegrated  tissues,  until  the 
enlarged    ulcerating    area    un- 
covers  the  surface  of  the  hone. 
The  entire  bone  is  exfoliated  to 
the  extent  of  the  necrosis  caused 
by    the     gummatous     infiltrate 
(osteitis  gummosa).     This  is  at- 
tended   with    the    expulsion    of 
round,  disc  shaped,  phagedenous 
fragments     which     are     slowly 
loosened  from  the  thickened  por- 
tion of  the  sclerosed  hone.  Wlien 
healthy  granuJatlori  tissue  prq- 
liferation  is  established,  healing 
begins ;  when  this  is  attained  the 
scar  tissue  of  the  soft  parts  be- 
comes adherent  to  the  bone.  The 
surface  of  the  bone  remains  per- 
manently thickened  and  irregu- 
lar in  outline,  especially  where  several  periosteal  gummata  coalesce,  as 
often  happens  on  the  bones  of  the  skull ;  the  hyperostosis  is  especially 
noticeable. 

Gummatous  Ostitis. —  Ostitis  gummosa  is  intimately  associated  with 
periosteal  gumma  and  is  sequential  to  it.  The  suppurative  form  fre- 
quently involves  the  thin  bones  of  the  hard  palate,  the  osseous  support 
of  the  nose,  and  the  bones  of  the  face.  Perforations  of  the  palate 
and  saddle  nose,  the  result  of  destruction  of  bone  and  collapse  of 
the  bridge  of  the  nose,  are  commonly  met  with  (Fig.  179).  When,  so- 
called  saddle  nose  is  not  due  to  traumatism,  it  is  alwaj^s  spyhilitic. 
Gumma  of  the  bone  and  osteophytes  of  the  lamina  vitrea,  and  of  the 


Fig.  179. —  Luetic  Saddle  Nose. 


SYPHILIS  503 

inner  aspect  of  the  orbital  cavity,  exert  pressure  upon  the  brain  and 
upon  the  optic  nerves. 

The  surfaces  of  bones  are  frequently  invaded  secondarily  hy  exten- 
sion from  gummata  located  in  contiguous  tissues.  In  prolonged  cases, 
the  frontal,  the  temporal,  and  the  bones  of  the  face  are  converted  into 
monstrous  malformations  or  are  destroyed. 

Gummatous  Osteomyelitis. — In  osteomyelitis  gummosa,  the  lesion 
develops  in  the  marrow,  in  the  spaces  of  the  spongiosa,  and  in  thef 
corticalis  of  the  bone  in  the  form  of  a  grayish  red  gelatinous  focus, 
which  varies  in  size  from  that  of  a  pea  to  a  nut,  and  later  undergoes 
fatty  degeneration.  It  ma}'  develop  without  appreciable  disturbance, 
or  may  be  attended  with  severe  hone  pain  {dolores  osteocopi).  The 
process,  which  is  often  multiple,  is  chronic  in  its  progress  and  slowly' 
destroys  the  bone,  while  th©  surrounding  osseous  tissue  becomes  thick 
and  dense.  When  several  adjacent  foci  coalesce,  a  considerable  seg- 
ment of  bone  is  robbed  of  nutrition  and  becomes  necrotic.  This  is, 
however,  a  prolonged  process  and  sequestration  may  not  occur  for 
years,  since  the  proliferation  of  healthy  granulations,  which  ultimately 
accomplish  demarcation  of  the  sequestrum,  is  exceedingly  slow. 

The  hones  pf  the  skull  (forehead  and  temporal  regions)  are  often 
the  seat  of  extensive  lesions  of  this  sort,  the  corticalis  and  the  inner 
table  being  permeated  by  the  luetic  process.  In  these  instances,  the 
macerated  bones  present  a  worm  eaten,  phagedenous  appearance,  al- 
though their  outlines  convey  the  impression  of  massive  hyperostosis. 
"When  suppuration  occurs,  the  picture  is  similar  to  that  presented  by 
a  broken  down  periosteal  gumma,  except  that  in  gumma,  the  phage- 
denous, disc  shaped  sequestra  are  very  large,  are  not  readily  separ- 
ated from  the  sclerotic  bone  surrounding  them,  and,  when  expelled, 
leave  large  deep  defects  often  extending  to  the  dura. 

In  the  short  tuhular  hones,  central  gummatous  infiltration  is  at- 
tended with  the  peripheral  deposit  of  layers  of  new  bone,  giving  the 
part  the  same  appearance  of  spina  ventosa  and  hottle  shaped  thick- 
ening that  is  common  to  iuherculous  osteomyelitis  in  this  location. 
This  phase  of  bone  syphilis  {dactylitis  syphilitica)  may  undergo 
ahsorption  or,  which  is  more  common,  extend  to  the  surrounding  soft 
parts,  break  down  and  form  ulcers  and  fi.stulae,  and,  at  times,  result  in 
necrosis  of  the  phalanx.  It  occurs  in  the  acquired  and  in  the  heredi- 
tary form  of  S3'philis ;  in  the  latter,  the  lesion  is  usually  multiple  and 
does  not  break  down  (Hochsinger-^). 

Syphilitic  caries  of  the  vertebrae  is  uncommon  but  occurs  at  times 


504 


INFECTIONS  OF  WOUNDS 


iu  the  cervical  region,  where  it  leads  to 
dangerous  malposition  of  the  spinal 
column. 

The  spongiosa  of  ihe  articular  ends  of 
the  diaphysis  is  rarely  involved.  Gum- 
matous infiltration  in  this  location  is 
tumor  like  in  form,  and,  when  rupture 
into  a  contiguous  joint  occurs,  it  is  fol- 
lowed by  extensive  destruction  of  the 
articular  apparatus.  Its  differentiation 
from  sarcoma  and  chronic  purulent  in- 
fection is  attended  with  considerable 
difficulty. 

The  diaphyses  of  the  long  tubular  hones 
(especially  in  the  leg  and  forearm)  are 
not  uncommonly  involved.  The  gumma- 
tous process  is  usually  central,  and  slowly 
leads  to  a  spindle  shaped  thickening  of 
the  bone.  Although  the  bone  surround- 
ing the  lesion  is  thickly  sclerosed,  the 
rarcfication  at  the  site  of  the  lesion  and 
the  infiltration  of  the  thickened  corticalis 
often  reduces  the  resistance  of  the  bone  to 
such  an  extent  that  moderate  trauma  is 
sufficient  to  fracture  it  (Fig.  180). 

Diffuse  syphilitic  periostitis  and  osteo- 
myelitis gummosa  frequentl^^  occur  in  the 
cranium  where  this  form  of  the  disease  is 
attended  with  extensive  destruction  of 
bone.  In  the  long  tubular  bones  (espec- 
ially in  the  forearm  and  leg)  it  rarely 
causes  suppuration  and  is  characterized 
by  massive  hyperostosis.  The  disease  fol- 
lows a  chronic  course  and  causes  a  sym- 
metrical thickening  of  the  bone  which,  at 
first,  is  sclerotic  in  nature  but  later  be- 
comes osteoporotic  and  is  easily  broken. 

In  childhood,  diffuse  gummatous  osteo- 
myelitis   (in  the  acquired  or  hereditary 


'Mi^^ 


l^} 


'A't 


Fig,  180. — Pathological  Frac- 
ture OF  THE  Shaft  of  the 
Eadius, 

Specimen  removed  from  a  man 
flfty-six  years  of  age,  who  had 
suffered  from  syphilis  for  six- 
teen years.  Fracture  occurred 
■while  the  patient  was  support- 
ing himself  upon  the  arm  while 
turning  over  in  bed.  A  doughy, 
fusiform  expansion  of  the  bone 
could  be  palpated.  The  skin 
covering  the  diseased  bone  was 
perfectly  normal.  (From  Volk- 
mann's  "Diseases  of  the  Or- 
gans  of   Locomotion.") 


SYPHILIS 


505 


forms)  involving  one  or  both  legs,  appears  in  the  form  of  an 
osteitis  deformans  suphilitica.  The  tibia  is  elongated,  bowed  anteri- 
orly, and  thickened,  so  that  the  anterior  curve  of  the  leg   is  more 


Pig.  181. —  Syphilitic  Osteitis  Deformaxs  (Thirty  Year  Old  Male  Patient) 

WITH   KONTGEN  EaY  PICTURE. 


marked  than  the  calf.  This  "saber  scabbard"  deformity  of  the  tibia 
is  due  to  a  peculiar  thickening  of  its  anterior  portion  and  an  over- 
growth of  its  entirety,  the  outcome  of  inflammatory  irritation.  The 
anterior  bowing  is  not  compensatory  (Schuchardt^^),  but  is  due  to 


506  INFECTIONS  OF  WOUNDS 

the  lack  of  corresponding  lengthening  of  the  fibula,  and  the  shortening 
of  the  muscles  (Wieting-*^).  It  is  differentiated  from  rachitis  hy  the 
absence  of  involvement  of  the  epiphyses,  and  of  other  bones  (Fig. 
181). 

Hereditary  syphilis  is  attended  with  a  peculiar  involvement  of  the 
epiphyses  called  osteochondritis  syphilitica.  Newborn  children  pre- 
sent painless  thickenings  of  the  epiphyses  which,  at  times,  are  separ- 
ated from  the  diaphyses,  so  that  the  affected  limb  appears  to  be 
paralyzed  {pseudoparalysis) .  In  other  instances  the  articular  appar- 
atus is  also  involved  in  the  process. 

The  pathological  changes  incident  to  osteochondritis  syphilitica 
(which  is  also  present  in  the  still  born)  occur  chiefly  in  the  centers 
of  ossification  W'here  an  unequal  deposit  of  lime  and  an  irregular 
development  of  medullary  sul)stance  cause  asymmetrical  growth.  The 
medullary  spaces  are  invaded  by  grajash  yellow,  degenerated  (hyaline 
or  fatty)  granulation  tissue  which  gradually  destroys  the  trabecuiae 
and  loosens  the  epiphysis  from  the  diaphysis.  In  addition  to  this, 
gummatous  foci  develop  in  the  medulla  of  the  bone  and  under  the 
periosteum;  the  latter  being  attended  with  the  growth  of  new  bone. 
The  disturbance  due  to  endochondral  growth  results  in  either  length- 
ening or  shortening  of  the  limb. 

General  friability  of  the  hones  (osteopsathyrosis)  occurs  in  con- 
nection with  prolonged,  severe  forms  of  syphilis,  as  the  result  of  dis- 
turbed general  nutrition  in  which  a  condition  of  so-called  cachexia  is 
developed,  similar  to  that  which  obtains  in  all  chronic  infectious  dis- 
eases. Lessening  of  the  quantity  of  fluorcalcium.  is  believed  to  be 
directly  responsible  for  their  increased  friability. 

The  diagnosis  of  hone  syphilis,  easy  as  it  is  in  typical  cases,  is 
difficult  in  the  atypical  ones,  especially  when  other  signs  of  lues  are 
absent.  Non-ulcerating  periosteal  gummata  resemble  deeply  located 
gouty  deposits  and  tuherculous  abscesses,  especially  when  these  are 
attached  to  the  bone  and  are  located  in  the  sl-ull,  the  forearm,  or  the 
hands.  Localized  thickening  of  bones  may  be  confused  with  chronic 
suppurative  or  tuberculous  foci,  and  with  central  or  periosteal  neo- 
plasm. General  hyperostosis  occurs  in  the  sclerotic  form  of  purulent 
osteomyelitis,  and  thickening  and  deformation  of  bones  also  attends 
the  ostitis  deformans  of  Paget,  both  of  which  must  be  taken  into 
account  in  the  differential  diagnosis.  When  the  history  of  the  case, 
together  with  the  serodiagnostic  method  of  Wassermann,^'^  fails  to 
justify  a  conclusion,   intensive  antisj^philitic  treatment  may  be  re- 


SYPHILIS  507 

sorted  to.  Edntgenographic  findings  are  valuable  only  when  the 
presence  of  new  bone  deposits  is  demonstrated  m  other  bones. 

The  treatment,  beyond  the  use  of  the  general  measures,  which  are 
effectual  only  in  the  early  stages  of  syphilitic  bone  lesions,  is  surgical. 
Painful  and  broken  down  foci  and  sequestra  are  exposed — using  the 
chisel  or  gouge  if  necessary — and  removed.  Persistent  suppurating 
periosteal  gumma  may  be  aspirated  or  exposed  dy  incision  and  curetted 
down  to  the  bone,  followed  by  the  open  wound  treatment. 

Defects  in  the  cranium  may  be  closed  by  osteoplastic  methods;  how- 
ever, extensive  loss  of  substance  may  be  compensated  for  by  the 
gradual  deposit  of  new  bone,  therefore,  operative  efforts  at  relief 
should  not  be  hastily  undertaken  (Hofmeister^'), 


F.    SYPHILIS  OF  JOINTS 

Syphilitic  arthritis  occurs  most  often  in  the  knee  and  elbow  joints. 

The  early  stage  of  acquired  lues  is  not  infrequently  attended  with 
a  picture  closely  allied  to  that  of  acute  articular  rheumatism  in  which 
the  joints  are  filled  with  a  serous  exudate  and  are  very  painful.  This 
manifestation  of  the  disease  soon  recedes  under  systemic  treatment 
and  immobilization  of  affected  joints. 

The  chronic,  usually  persistent  hydrops  of  late  lues,  is  due  to  the 
deposit  of  gummatous  infiltrate  in  the  synovia  or  in  the  articular 
<iartilage  of  the  joint.  The  knee  joint  is  most  frequently  attacked. 
It  rarely  suppurates  and  the  local  disturbances  are  moderate  in 
degree.  The  invaded  sjTiovia  is  thickened  and  covered  with  villous 
and  nodular  projections  of  proliferated  connective  tissue ;  the  articular^ 
cartilage  is  ulcerated,  especially  at  its  central  portion.  Healing  of 
these  ulcers  is  followed  by  small,  deep,  stellate,  cicatricial  defects 
(chondritis  syphilitica  of  Virehow^").  This  form  of  arthritis  results 
at  times  in  severe  arthritis  deformans   (Axhausen-^). 

Recognition  of  syphilis  of  joints,  especially  in  the  absence  of  coin. 
cident  manifestations,  is  not  easy.  The  simultaneous  invasion  of 
several  joints  by  a  low  grade  of  infection,  attended  with  moderate 
disturbances  of  function,  should  arouse  suspicion.  The  writer  has 
seen  a  positive  Wassermann  in  the  aspirated  fluid  of  joints  of  this 
sort. 

The  treatment  (beyond  systemic  medication)  consists  of  emptying 
the  joint  and  compression  l)y  bandaging.    Healing  follows  persistent 


508  INFECTIONS  OF  WOUNDS 

efforts  of  this  sort,  although  sequential  lessening  of  function  is  not 
rare,  especially  when  the  joint  capsule  is  much  thickened  and  the 
articular  cartilages  are  destroyed.  Grating,  on  motion  of  the  joint,  is 
indicative  of  the  latter.  The  removal  of  palpable  iumerous  deposits 
from  the  joint  capsule  has  been  followed  by  improvement  of  function 
(Borchard^^). 

The  severest  form  of  joint  lues  occurs  secondary  to  the  intra-articul- 
lar  rupture  of  an  intra-osseous  or  periosteal  lesion,  in  which  event  all 
the  ligaments  and  articular  cartilages  may  he  destroyed.  This  is  fol- 
lowed by  flail  joints  or  ankyloses  with  contractures  which  occur  most 
frequently  in  the  fingers  and  toes,  where  the  process  usually  extends  to 
the  soft  parts  (dactylitis  syphilitica). 

Acute  gummatous  arthritis  has  been  observed  in  cases  in  which  the 
joint  was  opened  under  a  mistaken  diagnosis  (Schuchardt^").  The 
process  appeared  in  the  form  of  multiple  gummata. 

Hereditary  syphilis  in  children  is,  at  times,  attended  with  the  rapid 
formation  of  serous  effusions  occurring  simultaneously  in  several 
joints  (often  in  the  knee  and  elbow).  This  is  either  the  result  of 
congenital  osteochondritis  syphiliiica,  or  is  due  to  gummatous  deposits 
.in  the  synovia  or  the  epiphyses.  Suppuration  rarely  follows.  Un- 
less there  are  other  signs  of  syphilis  present,  such  as  keratitis,  this 
form  of  joint  syphilis  is  likely  to  escape  recognition.  Systemic  antisy- 
philitic  treatment  usually  is  followed  by  recession  of  the  process. 
When  suppuration  occurs,  incision  and  drainage  are  indicated.  If 
there  is  much  destruction  of  tissue,  resection  of  the  joint  or  amputa- 
tion of  the  limb  may  be  necessary. 


G.  SYPHILIS  OF  TENDON  SHEATHS  AND  BURSAE 

Acute  exudative  inflarmnation  of  the  various  tendon  sheaths  and 
bursae  occurs  in  the  eruptive  stage  of  syphilis.  It  is  similar  to  the 
early  joint  effusions  and  like  these  usually  soon  subsides. 

Gummatous  deposits  at  times  occur  primarily  in  bursae,  especially 
at  the  knee  joint ;  they  develop  very  slowly,  with  little  or  no  pain, 
and  perforate  the  overlying  skin,  or  into  the  contiguous  joint.  The 
tendon  sheaths  and  bursae  may  also  be  invaded  secondarily  by  exten- 
sion from  gummata  located  in  the  skin  or  bone.  Tendon  sheaths  are 
most  often  invaded  from  ostitis  gummosa  in  cases  of  so-called  dacty- 
litis syphilitica. 


SYPHILIS  509 

Acute  joint  involvementj  a  part  of  the  eruptive  stage  of  the  disease, 
is  readily  recognized.  The  gummatous  form  is  difficult  to  diagnosti- 
cate unless  perforation  and  subsequent  typical  ulceration  occur,  to- 
gether with  additional  evidence  of  lues. 

The  treatment  consists  of  exposure  and  removal  (curettcment)  of 
the  lesion,  when  general  medication  does  not  accomplish  its  purpose. 


H.     VISCERAL  SYPHILIS 

Of  the  organs  susceptible  to  luetic  invasion,  the  "brain,  the  liver,  and 
the  testicle  possess  surgical  interest. 

Syphilis  of  the  Brain. — In  the  'brain,  syphilis  may  provoke  the 
formation  of  an  extensive  gummatous  nodule  presenting  the  picture 
of  tumor;  or  the  symptom  complex  may  be  caused  by  a  gummatous 
deposit  or  exostosis  of  the  tabula  interna,  making  pressure  upon  the 
cranial  contents.  In  connection  with  syphilitic  disease  of  the  cerebral 
arteries,  certain  sections  of  the  brain  undergo  transient  circulatory 
disturbances  or  are  permanently  softened,  giving  rise  to  more  or  less 
permanent  functional  paralysis;  or  the  arteriosclerosis  of  syphilis 
leads  to  rupture  of  a  vessel  (apoplexy),  the  distinguishing  feature  of 
which  is  its  occurrence  at  an  early  period  of  life. 

Syphilis  of  the  Liver. — Syphilis  of  the  liver  in  its  general  hepatitis 
interstitialis  form,  ig  of  less  surgical  importance  than  is  the  nodular 
form.  It  resembles  most  closely,  nodular  carcinoma.  However,  luetic 
nodules  are  not  as  hard  as  those  of  carcinoma  and,  in  the  former,  the 
liver  is  usually  found  retracted  bcj^ond  the  border  of  the  ribs  by  con- 
tracture of  the  connective  tissue  proliferated  between  the  gummata. 

Syphilis  of  the  Tes.dcle. — In  the  testicle,  syphilis  provokes  (beside 
orchitis  luetica)  the  development  of  extensive  gummatous  deposits 
which,  preliminary  to  rupture  and  ulceration,  are  difficult  to  differen- 
tiate from  hard,  nodular,  malignant  7ieoplasms,  unless  the  latter  are 
attended  with  involvement  of  the  contiguous  glands. 

Regarding  the  prognosis  of  syphilis,  it  is  worthy  of  note  that  the 
cases  coming  under  the  care  of  the  surgeon  are  usually  of  the  late 
stages  of  the  disease,  that  have  been  either  of  a  virulent  type  or  have 
not  been  carefully  treated.  In  the  gummatous  period  of  syphilis  the 
removal  of  a  local  lesion  may  be  successfully  accomplished,  yet  the 
patient  may  soon  die  because  of  an  indiscernible  involvement  of  an 
important  vital  organ. 


510  INFECTIONS  OF  WOUNDS 

THE  GENERAL  TREATMENT  OF  SYPHILIS 

In  the  general  treatment  of  syphilis,  the  position  so  long  occupied 
by  the  various  preparations  of  mercury  and  iodi7i,  must  now  be 
shared  with  Ehrlich  V  salvarsan. 

Mercury. — Mercury  is  administered  in  several  ways.  The  inunction 
method,  which  is  the  oldest,  consists  of  anointing  the  skin  of  the 
various  portions  of  the  body  with  unguentum  hydrargyri  cinereum 
(33.5  per  cent),  using  4-5  gm.  in  the  adult  and  0.5-2  gm.  in  children, 
each  morning,  so  that  the  cycle  of  the  body  is  completed  in  six  days. 
This  is  maintained  for  at  least  thirty  days.  The  method  is  a  good 
one  and  is  less  often  followed  by  symptoms  than  are  the  others.  How- 
ever, it  has  certain  disadvantages ;  the  anointing  is  not  alwaj's  feasible, 
the  dosage  is  difficult  to  control,  and,  in  a  number  of  cases,  it  pro- 
yokes  stomatitis  mercuralis  attended  with  inflammation  and  ulceration 
of  the  gums,  loosening  of  the  teeth,  fetid  breath,  and  salivation. 

Siibcutaneous  or  iyitramuscular  injection  (into  the  gluteal  region) 
of  soluble  and  insoluble  preparations  of  mercury  is  much  employed. 
Neisser^^  uses  forty  per  cent  mercurol  (ol.  cinereum,  1/4  cm.-0.14  Hg.), 
and  asurol  (a  soluble  double  salt,  with  40.3  per  cent  mercury,  0.1 
asurol)  two  to  three  times  weekly. 

The  internal  administration  of  mercury  is  useful  but  causes  dis- 
turbances of  digestion.  Its  greatest  usefulness  lies  in  the  adminis- 
tration of  small  doses  to  children.  The  hydrargyrum  iodidum  flavum 
(up  to  0.02  gm.  or  0.03  gm.)  in  pill  form  or  small  doses  of  calomel 
are  very  largel}^  used. 

lodin. — The  iodin  preparations  (potassium  and  sodium  iodid — 
iodophenin)  exercise  a  beneficial  effect  on  the  lighter  forms  of  late 
syphilis  and  may  be  advantageously  given  together  with  mercury. 
The  iodid  treatment  is  extensively  used  for  purposes  of  differential 
diagnosis,  though  salvarsan,  because  of  its  rapid  action,  may  be  re- 
garded as  more  useful  in  this  connection,  especially  since  a  serodiag- 
nostie  reaction  cannot  be  regarded  as  indicative  of  the  character  of 
a  local  lesion.  In  any  event,  in  cases  of  tumor  which  present  evidence 
of  malignancy,  the  so-called  diagnostic  treatment  should  not  be  ex- 
tended over  two  weeks. 

The  prolonged  administration  of  the  iodin  preparations  leads  to 
a  catarrhal  irritation  of  the  mucous  membrane  of  the  eyes,  nose, 
pharynx,  larynx,  and  bronchial  tubes  which,  together  with  headache 
and  digestive  disturbance,  are  grouped  under  the  term  iodism;  when 
the  remedy  is  discontinued  they  soon  disappear.    Certain  patients  are 


SYPHILIS  511 

able  to  take  the  sodium  or  calcium  iodid  (Frc}-^^)  for  a  long  period  of 
time  without  developing  symptoms  of  iodism. 

Arsenic. — Of  the  arsenic  'preparations,  atoxijl,  because  of  its  poison- 
ous etTects,  is  no  longer  used. 

Ehrlich's^^  preparation  (Ehrlich-Hata^^.  606 — di-amido-arsenoben- 
zol;  salvarsan,  trade  name)  exercises  a  peculiar  specific  effect  upon 
spirochetes.  Intravenous  injection  of  0.5  to  0.6  gm.  of  the  prepara- 
tion rapidly  destroys  them,  and  the  lesions  of  syphilis,  especially  those 
of  the  early  stages,  soon  disappear  or  cicatrize.  However,  the  early 
notion  that  a  single  administration  of  salvarsan  resulted  in  a  com 
plete  eradication  of  the  disease  has  been  found  erroneous.  At  the 
present  writing,  it  would  seem  that  best  results  are  obtained  by 
repeated  intravenous  injections  of  increasing  doses  of  salvarsan  (two 
to  three  injections  of  from  0.5  to  1.0  gm.,  at  intervals  of  two  weeks) 
together  with  the  administration  of  mercury  (Neisser,^*  Scholtz,^^ 
etc.).    Even  under  these  conditions,  recurrences  are  not  excluded. 

Salvarsan  is  hest  given  intravenously  in  neutral  or  slightly  alkaline 
solution  (the  dose  is  diluted  to  200  c.cm.  with  normal  salt  solution). 
Subcutaneous  and  intramuscular  injection  of  the  preparation  (given 
undiluted)  is  often  followed  by  the  formation  of  hard  zones  of  infil- 
tration, abscesses,  and  ulcers.  The  injections  are  at  times  followed 
by  general  disturbances — chill,  fever,  vomiting,  and  diarrhea — which 
may  be  due  to  the  sudden  destruction  of  the  spirochetes  and  conse- 
quent liberation  of  endotoxins  (Xeisser^^).  They  are  also  followed 
by  exanthematous  eruptions  and,  occasionally,  by  paralysis  of  certain 
cranial  nerves  (facial,  trochlear,  abducens,  motor  oculi,  and  auditory). 
The  nerve  symptoms  may  be  ascribed  to  the  disease  rather  than  to 
the  toxicity  of  the  preparation ;  however,  it  is  certain  that  they  occur 
more  frequently  when  salvarsan  is  used  than  when  mercury  is  adminis- 
tered. 

Neosalvarsan,  EhrlichV^  modification  of  his  original  preparation, 
has  the  advantage  of  being  directly  soluble  in  water  and  neutral  in 
reaction.  It  would  seem,  however,  not  to  be  as  eificacious  as  is  sal- 
varsan ("Wolff  and  Mulzer^^). 

Fatal  outcome  has  followed  the  use  of  salvarsan  in  a  sufficient  num- 
ber of  cases  to  v/arrant  care  in  the  selection  of  suitable  subjects.  Its 
use  is  contra-indicated  in  advanced  cardiac  or  arterial  disease,  old 
age,  lesions  of  the  central  nervous  system,  tabes  dorsalis,  progressive 
paralysis,  ulcer  of  the  stomach,  and  luetic  affections  of  the  ej-eball  or 
optic  nerves. 


512  INFECTIONS  OF  WOUNDS 

BIBLIOGRAPHY 

1.  ScHAUDiNN  and  Hoffmann.     Arb.  a.  d.  kais.  Gesundheitsamt.  Bd.  22, 

1905 ;  also  Berlin,  klin.  AVoch.,  1905. 

2.  SoBERNHEiM  and  ToMASczEWSKi.     Miinch.  med.  Woch.,  1905. 

3.  Spitzer.     Wien  klin.  Woch.,  1905. 

4.  MuLZER.     Berlin,  klin.  Woch.,  1905;  also  Arch.  f.  Dermat.  u.  Syph.  79, 

1906. 

5.  Bandi  and  Simonelle,     Zentrbl.  f.  Bakt.  40,  1905. 

6.  Levaditi  et  Petresco.     Presse  med.,  1905. 

7.  TOMASCZEWSKi.     Miinch.  med.  Woch.,  1906. 

8.  EwiNG.     Proc.  K  Y.  Path.  Soe.  N.  S.  5,  1905. 

9.  DouTRELEPONT  and  Grouven.     Deutsch.  med.  Woch.,  1906. 

10.  NoGUCHi  and  Moore.     Jr.  Exp.  Med.  xvii,  1913. 

11.  Uhlenhuth   and   Mulzer.     Arb.  a.   d.   kais.   Gesundheitsamt,   Bd.   33, 

1909 ;  also  Berlin,  klin.  Woch.,  1911, 

12.  MiJiiLENS.     Berlin  med.  Woch.,  1909. 

13.  ScHERESCHEWSKY.     Deutsch.  med.  Woch.,  1909,  Nos.  19,  29,  38. 

14.  Lesser.     Geschlechtskrankheiten,  Leij^zig. 

15.  ViRCHOw.     Die  Krankhaften  Geschwiilste,  Bd.  ii. 

16.  BoRDET  and  Gengou.     Ann.  de  I'inst.  Pasteur,  1901. 

17.  Wassermann,  Neisser  and  Bruck.     Deutsch.  med.  Woch.  xix,  1906; 

Wassermann,  Neisser,  Bruck  and   Schucht  —  Zeitsehr.  f .  Hyg.  Iv, 
1906. 

18.  WoLFSOiiN.    Deutsch.  Med.  Woch.,  1910. 

19.  HoxsELL.     Beitr.  z.  klin.  Chir.  Bd.  22,  1898. 

20.  0.  BussE.     Arch.  f.  klin.  Chir.  Bd.  69,  1903. 

21.  V.  Bramann.     Berlin  klin.  Woch.,  1889. 

22.  Landois.     Beitr.  z.  klin.  Chir.  Bd.  63,  1909. 

23.  V.  ESMARCH.     Chir.  kong.  Verb.,  1895,  ii. 

24.  HocHSiNGER.     Festschr.  f.  Kaposi  Wien,  Leipzig,  1900. 

25.  ScHUCHARDT.     Die  Krankh.  d.  Knochen  and  Gelenke,  Stuttgart,  1899, 

with  complete  lit. 

26.  WiETiNG.     Beitr.  z.  klin.  Chir.  Bd.  30, 1901. 

27.  HOFMEISTER.     Beitr.  z.  klin.  Chir.  Bd.  13,  1895. 

28.  AxHAUSEN.     Berlin  klin.  Woch.,  1913. 

29.  BORCHARD.     Deutsch.  Zeitsehr.  f.  Chir.  Bd.  61,  1901. 

30.  Ehrlich,     Miinch.  med.  Woch.,  1911. 

31.  Neisser.     Therap.  Monatsheft,  1909. 

32.  Frey.     Med.  Klinik,  1914. 

33.  Ehrlich  and  Hata.      Die  exp.  Chemotherapie  der  spirillum,  Berlin,  1910. 

34.  Neisser.     Jadassohn's  Samml.  a.  d.  Gel),  d.  Derm.  u.  Syph.  Bd.  i,  1911. 

35.  ScHOLTZ.     Deutsch  med.  Woch.,  1912,  No.  7. 

36.  Wolff  and  Mulzer.     Miinch.  med.  Woch.,  1912,  No.  31. 


CHAPTER  XXVI 


SCLEEOMA 


Scleroma  of  the  nasal  mucous  jnemhrane,  the  pharynx,  and  the 
larnyx,  first  described  by  Hebra  and  Kaj^osi  in  1870,  is  a  rare  affliction 
characterized  by  a  progressive  proliferation  of  tissue.  It  usually 
occurs  in  the  adult  and  is  not  contagious. 

The  process  is  believed  to  be  an  infectious  proliferation  of  granu- 
lation tissue  (similar  to  tuberculosis,  lues,  actinomycosis,  lepra,  and 
malleus)  and  usually  begins  in  the  nasopharynx  or  in  the  choanae  and 
extends  to  and  involves  the  mucous  membrane  and  skin  of  the  nose, 
lips,  and  cheeks ;  it  also  invades  the  gums,  the  tongue  and  the  upper 

air  passages.  Scleromatous  lesions 
may  also  appear  primarily  in  the 
pharynx,  the  larynx,  and  trachea. 

The  disease  folloM's  a  chronic 
course,  and  its  progress  is  not  at- 
tended with  pain.     The  affected 

MUCOSA  IS  INVADED  BY  A  NODULAR 
OR  FLAT  INFILTRATE  OF  CARTILAGIN- 
OUS CONSISTENCE;  IT  IS  SHARPLY 
DEFINED  OR  MAY  MERGE  GRADUALLY 
INTO      THE      SURROUNDING     TISSUES. 

The  skin  or  mucous  membrane  is 
red,  tense,  and  traversed  by  large  veins;  and  it  is  intimately  asso- 
'ciated  with  the  proliferated  granulation  tissue.  It  may  be  dry  and 
cracked  or  ulcerated.  It  rarely  ulcerates  deeply,  but  often  forms 
hard,  contracted  cicatrices.  The  underlying  cartilage  is  fibrillated  or 
hyperplastic. 

As  cicatricial  contracture  progresses,  the  nose  becomes  patent,  whilst 
the  proliferation  in  the  pharynx,  in  the  lar^-nx,  and  at  the  epiglottis 
often  causes  obstruction  to  breathing  and  interference  with  degluti- 
tion. When  the  skin  of  the  nose  is  invaded,  it  broadens,  becomes  hard, 
deformed,  and  bluish  red  in  color.    The  alae  of  the  nose  stand  out  in 

513 


Fig.  182. —  Scleroma  of  Nasal 
Mucosa. 


514  INFECTIONS  OF  WOUNDS 

a  position  of  permanent  dilation,  while  the  lips,  when  affected,  are 
the  seat  of  large  nodular  masses. 

As  time  goes  on  the  patient  develops  a  cachexia,  or  the  lungs  are 
gradually  invaded;  these  conditions,  however,  do  not  occur  until  the 
disease  has  existed  for  several  decades. 

Scleroma  resembles  sarcoma,  carcinoma,  and  syphilis;  in  doubtful 
cases,  microscopical  examination  of  a  section  of  the  lesion  should  result 
in  their  differentiation. 

The  treatment  consists  of  early  removal  of  the  lesion,  but  is  un- 
satisfactor}^,  as  the  process  usually  recurs.  When  complete  excision  of 
the  lesion  is  impossible,  portio7is  of  it  may  he  removed  with  the  view 
of  obviating  mechanical  obstruction.  In  scleroma  of  the  larynx, 
tracheotomy  may  be  necessary  to  prevent  strangulation,  v.  Riidiger- 
Rydygier^  claims  to  have  benefited  scleroma  of  the  nasal  passage  and 
larynx  by  exposure  to  the  Rontgen  ray. 

Microscopical  examiyiation  of  the  affected  tissue  shows  it  to  be 
thickly  invaded  by  proliferated  connective  tissue  (especially  in  the 
vicinity  of  the  blood  vessels)  which  contains  peculiar  degenerated  cells 
(v.  Mikulicz^  cells) .  A  portion  of  the  cells  are  large  and  swollen,  and 
contain  vacuoles  filled  with  bacilli,  while  others  are  in  a  state  of  hya- 
line degeneration  and  contain  free,  circular,  hyaline  masses.  A  num- 
ber of  bacteria  are  found  in  the  lymph  spaces  and  in  the  cells. 

The  cause  of  scleromatous  infiltration  of  mucous  membranes  is 
generally  believed  to  be  bacterial.  The  hacillus  of  scleroma,  described 
by  V.  Friscli^  (1882)  as  the  causative  excitant,  is  a  plump,  short  rod 
with  rounded  ends,  morphologically  identical  with  Friedlander's 
bacillus;  it  is  non-motile  and  j^ossesses  a  distinct  capsule.  Its  causative 
relationship  to  scleroma  is  difficult  to  prove,  since  it  cannot  be  readily 
dissociated  from  other  bacteria  (Friedlander's  pneumobacillus,  the 
ozena  bacillus)  with  which  it  is  commonly  found  in  the  nose. 

BIBLIOGRAPHY 

1.  v.  Rudiger-Rtdygier.     Zentrbl.  f.  Chir.,  1911. 

2.  v.  Mikulicz.     Arch.  f.  Chir.  xx,  1876. 

3.  V.  Frisch.     Wien  med.  Woch.,  1882. 


CHAPTER  XXVII 
BOTKYOMYCOSIS 

Bollinger^  describes  botryomycosis  as  an  infectious  granulomatous 
invasion  of  the  skin  attended  with  the  presence  of  large  numbers  of 
micrococci  {lotrijococci)  which  are  arranged  in  the  tissues  in  the 
form  of  clusters  of  grapes  or  mulberries  and  possess  almost  the  same 
cultural  characteristics  as  the  staphylococcus  -pyogenes  aureus,  but 
may  be  differentiated  from  the  latter  after  inoculation  into  horses. 

In  man,  the  disease  was  first  recognized  by  Poncet  and  Dor^  (1897). 
The  lesion,  as  described  by  Legrain,^  appears  in  the  form  of  a  nodular 
tumor  of  the  skin  the  size  of  an  adult  fist ;  it  has  an  ulcerated  surface 
that  bleeds  very  readily;  it  is  soft,  red  in  color,  and  is  attached  to 
the  skin  by  a  short,  thin  pedicle  which  is  surrounded  by  a  collar  of 
epidermis.  These  granulomata  grow  \ery  slowly,  are  not  painful  and 
usually  are  found  on  the  fijigers,  though,  at  times,  they  are  found 
upon  the  hands,  arms,  forehead,  back,  and  other  portions  of  the  body. 

Complete  excision  is  readily  accomplished,  as  they  do  not  form  deep 
attachments. 

Botryomycotic  granulomata  may  be  mistaken  for  an  angiosarcoma 
which  at  times  occurs  on  the  fingers  in  the  form  of  small  (size  of  a 
cherry)  pediculated  tumors.  The  microscopical  identification  of  the 
cocci  makes  the  diagnosis  certain. 

According  to  Bennecke'*  and  Kiittner,^  the  granulomata  found  in 
man  have  nothing  in  common  with  the  botr^^omycosis  of  the  lower 
animals.  These  observers  consider  the  lesion  to  be  a  granulomatous 
tumor  of  unknown  etiology,  characterized  by  the  presence  of  numer- 
ous dilated  capillaries  (telangiectatic  granuloma). 


515 


516 


INFECTIONS  OF  WOUNDS 


Fig.  183. —  Granuloma  Pyogenicum.     So-called  botryomycosis  hominis   (Pusey). 


2. 
3. 
4. 
5. 


BIBLIOGRAPHY 

Bollinger.  Quoted  by  Gahinet  —  Les  tumeurs  botryomycosiques  chez  le 
eheval  et  chez  I'homme,  Paris,  1902.  Michalon,  with  lit.,  and  by  Glace 
in  Kolle-Wassermann  Handb,  d.  path.  Microorg.  Aufl.  ii,  Bd.  6,  1913, 
with  lit. 

PoxcET  and  Dor.     Same  as  Bollinger  No.  1. 

Legrain.     Aroh.  de  Parasitologie,  1898. 

Bennecke.     Miineh,  med.  Woch.,  1906. 

KiJTTNER.     Beitr.  z.  klin.  Chir.,  Bd.  47,  1905. 


PAET  III 

NECROSIS 


CHAPTER  I 

NECEOSIS  —  GENERAL   CONSIDERATIONS 

Disturbances  in  the  nutrition  of  traumatized  tissues  and  the  patho- 
genesis of  parts,  the  nutrition  of  which  is  interfered  with  as  the 
outcome  of  changes  in  the  Mood  vessels,  form  a  considerable  portion  of 
the  responsibility  encumbent  upon  the  surgeon.  If  the  measures  of 
relief  are  ineffectual,  death  of  tissue  is  the  inevitable  result.  This  is 
called  necrosis  and,  because  of  the  carbonaceous  appearance  of  the 
part,  is  also  called  gangrene. 

Disturbances  of  nutrition  are  synonymous  with  disturbances  in  the 
circulation  of  the  Mood,  as  the  lymph  stream,  even  though  not  directly 
interfered  with,  is  not  capable  of  taking  care  of  the  nutrition  of  con- 
siderable areas  of  tissue. 

Disturbances  of  circulation  follow  accidentally  inflicted  or  opera- 
tive wounds  which  involve  the  division  or  ligature  of  large  blood 
vessels,  the  subcutaneous  rupture  of  their  branches  and  pressure  upon 
the  tissues  of  hematomata,  and  the  pathological  dilation  or  narrowing 
of  their  lumen.  The  outcome  of  circulatory  disturbances — either 
return  to  the  normal  or  death  of  tissue — depends  upon  the  degree  of 
interference,  and  upon  whether  the  onset  of  the  circulatory  interrup- 
tion is  sudden  or  gradual;  whether  the  cause  is  removed  early  or  late, 
and  finally  upon  whether  the  collateral  circulation  is  sufficient 
promptly  to  nourish  the  excluded  area. 

To  these  factors  may  be  added  the  general  and  local  conditions. 
Reduction  of  general  resistance  and  cardiac  insufficiency  are  as  inimi- 
cal to  restitution  to  the  normal  on  the  part  of  the  excluded  domain, 
after  the  circulation  has  been  reestablished,  as  is  the  pressure  from 
hematomata  and  inflammatory  processes;  the  existence  of  diseased 
blood  vessels;  or  constriction  resulting  from  improperly  applied  band- 
ages or  faulty  posture  of  an  affected  limb. 

The  character  of  tissue  involved  in  the  circulatory  disturbances  also 
has  a  bearing  on  the  likelihood  of  necrosis.  Bones,  cartilage,  tendons, 
and  fascia  survive  exclusion  from  the  circulation  for  a  long  time,  while 

519 


520  NECKOSIS 

the  skin,  muscles,  and  nerves  soon  succumb.  The  lymphatic  cells  of 
organs  and  the  elements  of  the  central  nervous  system  become  necrotic 
in  a  few  hours. 

In  muscles  and  nerves,  transient  ischemia  of  about  five  hours'  dura- 
tion results  in  dege^ieration  and  severe  functional  disturbances  (con- 
tractures and  paralyses). 

Externally,  interference  with  the  arterial  circulation  of  a  part  is 
manifested  by  ischemia;  when  return  circulation  is  obstructed,  passive 
hyperemia  or  stasis  develops.  This  is  well  illustrated  in  the  pedicu- 
lated  method  of  plastic  repair  when  the  pedicle  is  too  small  or  sub- 
jected to  pressure.  "When  the  blood  supply  is  insufficient,  the  flap 
becomes  pale  and  cold,  its  edges^ — if  there  is  no  inflammation — become 
dry  and  the  entire  flap  is  converted  into  a  brown  or  black  crust.  If 
the  venous  circulation  is  interfered  with,  the  flap  swells,  becomes  blue 
in  color  or  is  flecked  with  blue  areas.  The  dilated  capillaries  and  blood 
vessels  are  paralyzed  so  that  their  walls  permit  of  the  transudation  of 
blood ;  the  red  blood  corpuscles  disintegrate  and  give  up  their  coloring 
matter  which  stains  the  tissues  a  deep  purplish  red  or  black.  In  the 
same  way,  the  serum  which  collects  in  the  epidermal  hlebs  is  also  stained 
red.  The  surface  of  the  flap  is  spotted  with  numerous  hemorrhagic 
areas  that  correspond  to  the  site  of  ruptured  blood  vessels.  At  first, 
incision  of  the  flap  liberates  dark,  indolently  flowing  blood ;  when  this 
ceases,  thrombosis  has  occurred  and  the  fate  of  the  flap  is  sealed. 
The  epidermis  loosens  and  is  cast  off  in  shreds,  exposing  the  discolored 
corium  which,  together  with  the  entire  flap  (unless  putrefaction  de- 
velops), is  soon  converted  into  a  hard,  black  mass. 

Moderate  circulatory  disturbances,  the  result  of  lessened  arterial 
supply  or  of  interference  with  venous  return,  may  persist  for  years 
before  necrosis  develops.  The  reduced  resistance  thus  developed  in 
the  tissues  is  manifested  by  the  persistence  of  skin  eruptions,  delayed 
repair  of  accidentally  produced  wounds,  and  by  a  peculiar  suscepti- 
bility to  bacterial  infection,  all  of  which  may  be  observed  in  connec- 
tion with  varicose  ulcers  of  the  leg,  diabetic  gangrene,  and  in  cases 
of  angiosclerotic  necrosis. 

While  disturbances  of  the  circulation  are  frequently  the  cause  of 
necrosis,  they  are  not  the  oidy  etiological  factors.  A  certain  area  of 
tissue  is  frequently  destroyed  as  the  result  of  crushing  trauma  or  by 
chemical  and  thermal  influences,  so  that  the  protoplasm  of  the  cell  is 
no  longer  capable  of  taking  up  nutritive  elements,  even  though  these 
be  furnished  by  the  circulatory  fluid. 


GENEKAL  CONSIDERATIONS  521 

Death  of  tissue  is  commensurate  with  the  degree  of  circulatory  in- 
terference and  may  develop  rapidly  or  gradually.  In  the  latter 
instance,  necrosis  is  preceded  by  cell  degeneration.  Pathologists  call 
immediate  death  of  tissue,  necrosis.  "When  is  it  preceded  hy  cell  de- 
g-eneration  (especially  in  organs),  the  term  nccrohiosis  is  emploj'ed. 

Clinicalhj,  necrosis  is  divided  into  the  dry  and  the  wet  form.  Dry 
necrosis  (necrosis  sicca,  mummiformis)  develops  as  the  result  of  the 
evaporation  of  tluids  and  begins  in  the  portions  of  skin  denuded  of 
epidermis,  gradually  extending  to  the  deeper  structures  until  the 
entire  part  is  hard,  dry,  and  shrunken.  Wet  necrosis  {necrosis  hu- 
mida)  occurs  where  tissue  is  edematous  before  necrosis  begins  and 
notably  where  infection — especially  the  putrefactive  form — is  respon- 
sible for  the  transudation  of  fluid,  a  condition  of  affairs  which  occurs 
to  a  greater  or  less  degree  in  all  severe  pyogenic  or  putrid  infections. 
The  term  gangrene  should  be  applied  only  to  wet,  putrid,  gangrenous 
processes,  in  order  to  avoid  confusing  the  terms  gangrene  and  ne- 
crosis. 

The  herders  of  dead  areas  are  surrounded  with  granulation  tissue, 
as  occurs  in  connection  with  efforts  on  the  part  of  the  body  to  get  rid 
of  foreign  bodies,  and  in  all  inflammatory  processes  (p.  16).  The 
leukocytes,  associated  with  the  formation  of  granulations,  liberate 
ferments  which  loosen  the  dead  from  the  healthy  tissue  surrounding 
it.  Gradually  the  proliferation  of  granulation  tissue  creates  an  in- 
creasing line  of  demarcation  and  a  ditch,  which  is  usually  filled  with 
fluid,  is  formed  between  the  wall  of  gramdations  formed  by  the  healthy 
tissues  and  the  area  of  necrosis. 

Complete  separation  of  a  necrotic  area  of  tissue,  or  a  sequestrum, 
is  accomplished  when  the  layer  of  proliferated  granulations  completely 
separates  the  dead  from  the  living  parts.  In  accord  with  the  charac- 
ter of  tissue  involved,  this  process  is  accomplished  in  varying  periods 
of  time;  for  instance,  necrotic  skin  raaj  be  separated  in  from  one  to 
two  weeks,  while  dead  bone  requires  from  two  to  three  months. 


CHAPTER  II 

NECEOSIS    DUE    TO    TRAUMA 

The  Direct  Result  of  Trauma,  and  Following  Injuries  op 
Blood  Vessels 

Necrosis  as  a  Direct  Result  of  Trauma. — Portions  of  tissue  entirely 
separated  from  their  attachments  promptly  undergo  necrosis  unless 
special  conditions  favorable  to  their  reattachments  exist.  This  of 
course  rarely  obtains  in  connection  with  accidentally  avulsed  portions 
of  tissue,  which  are  usually  crushed  by  the  trauma  and  are  particu- 
larly susceptible  to  bacterial  infection.  AVhen  portions  of  tissue  are 
used  for  purposes  of  free  transplantation,  conditions  favorable  to  their 
viability  are  created  by  the  surgeon  (p.  19). 

Blunt  force  is  frequently  responsible  for  necrosis  of  tissue.  As  this 
class  of  trauma  is  attended  with  thrombosis  of  the  crushed  blood  ves- 
sels and  consequent  disturbance  of  the  circulation,  it  usually  is 
promptly  followed  by  necrosis.  In  this  way,  severe  injuries  by  ma- 
chinery, which  cause  extensive  crushing  of  the  tissues  and  tearing 
of  the  blood  vessels,  often  lead  to  necrosis  of  an  entire  extremity. 
Necrosis  of  areas  of  skin  separated  from  the  underlying  parts  by  a 
tearing  or  crushing  force  is  a  common  occurrence. 

Necrosis  Following  Injuries  of  Blood  Vessels. — The  rupture,  injury 
or  ligature  (for  malignant  tumor  or  aneurism)  of  the  main  artery  of 
an  organ  or  limb  causes  necrosis  of  the  excluded  part  when  sufficient 
anatomical  collateral  circulation  is  not  available,  or  when  the  col- 
lateral blood  vessels  are  insufficient  for  the  purpose  as  the  result  of 
general  feebleness,  of  arterial  disease,  or  because  of  the  pressure  of 
an  inflammatory  exudate  or  hematoma  which  occludes  them. 

Organs,  the  hloocl  vessels  of  which  have  heen  ligated,  necrose  very 
rapidly;  this  may  be  observed  in  the  testicle  which  rapidly  atophies 
when  the  spermatic  artery  is  tied  during  an  operation  for  the  relief 
of  hernia,  or  when  all  the  veins  are  tied  in  connection  with  the  opera- 
tion for  varicocele.     The  same  is  true  with  regard  to  the  kidney,  the 

522 


NECROSIS  DUE  TO  TRAUMA  523 

spleen,  and  the  gut  where  the  circulation  is  terminal.  In  the  brain, 
insular  necrosis  follows  forty  per  cent  of  the  cases  in  which  the  internal 
carotid  is  tied  on  one  side. 

In  the  extremities,  circulatory  exclusion  is  followed  by  necrosis;  in 
the  lower  limbs  more  often  than  obtains  in  the  upper  extremities, 
though,  in  either  instance,  the  degree  of  necrosis  varies  greatly  under 
seemingly  similar  conditions. 

Ewald  Wolff's^  statistics  show  that  necrosis  followed  ligature  of 
the  common  iliac  artery  in  fifty ;  of  the  femoral,  above  the  profunda, 
in  twenty-five;  of  the  popliteal  in  fifteen;  of  the  axillary  in  fifteen; 
and  of  the  subclaA-ian  and  brachial  in  four  and  eight  tenths  per  cent 
of  the  cases.    OppeP  advises  simulatneous  ligature  of  the  accompany- 


FiG.  18-4. — •Necrosis  (Dry  Gangrene)  of  the  Arm  following  Eupture  of  a 
Diseased  Axillary  Artery  while  Attejipting  to  Reduce  ax  Old  Disloca- 
tion OF  the  Shoulder. 

Patient  M-as  a  Avoman  sixty-nine  years  of  age.  Appearance  of  arm  four  weeks 
after  ligation  of  the  artery. 

ing  vein  with  the  view  of  favoring  collateral  circulation,  in  which  he 
is  supported  by  BakkaP. 

In  any  event,  it  is  certain  that  the  function  of  limhs  is  often  re- 
tained after  ligature  of  the  main  arterv^  and  in  some  instances 
where  both  the  artery  and  the  vein  are  tied.  In  a  general  way  it  may 
be  said  that,  under  these  conditions,  the  lower  extremity  is  more 
likely  to  necrose  than  is  the  upper.  When  necrosis  occurs  under 
ordinary  conditions,  it  is  fair  to  assume  that  the  collateral  circulation 
is  interfered  with.  In  this  connection  the  causative  factors,  other  than 
general  debility  and  cardiac  insufficiency,  may  be  stated  as  follows: 
Loss  of  hJood  from  the  injur}'  or  the  operation;  the  condition  of  the 
blood  (anemia,  diabetes,  infectious  diseases)  ;  arteriosclerosis;  phlehec- 


524  NECROSIS 

tasis;  thromlosis;  inflammations;  and  interference  with  the  circula- 
tion by  bleeding-  under  fascia,  tiglit  bandaging,  and  dependent  position 
of  the  limb. 

In  the  extremities,  the  clinical  picture  of  the  onset  of  necrosis  is 
characterized  by  ischemia  or  venous  hyperemia.  The  excluded  portion 
of  the  limb  is  pale,  cold,  and  pulseless,  or  the  skin  is  edematous  and 
mottled  white  and  red;  or  it  may  present  a  dark  blue  color  and  be 
covered  with  large  necrotic  blebs.  The  distal  portions  of  the  limb  are 
most  severely  involved.  At  first  the  limb  is  paresthetic  and  dully  pain- 
ful, but  soon  becomes  fully  anesthetic  and  motionless,  the  result  of 
sensory  and  motor  paralysis  (ischemic  muscles  lose  electrical  excit- 
ability in  five  hours).  Pain  in  the  necrosed  area  is  severe  and  is  due 
to  peripheral  conveyance  from  the  nerves  at  the  line  of  demarcation. 
Motor  paralysis  is  delayed  until  the  muscles  are  disintegrated.  The 
process  begins  at  the  end  of  two  days  in  the  fingers  and  toes  in  the 
form  of  dry  or  wet  necrosis  or  gangrene  and  gradually  extends  over 
the  entire  excluded  zone.  In  less  severe  cases  it  is  restricted  to  the 
tips  of  the  fingers  and  toes,  or  to  insular  areas  of  the  sl'in  of  the  hand 
or  foot.  These  heal  after  separation  of  the  necrotic  areas.  Necrosis 
rapidly  follows  infection  of  accidentally  inflicted  wounds.  At  times 
secondary  infection  develops  at  the  site  of  the  line  of  demarcation 
(phlegmon,  lymphangitis,  etc.)- 

Necrosis  of  organs  presents  a  clinical  picture  which  varies  with 
the  organ  involved,  and  is  characterized  by  disturbances  of  its  func- 
tion. In  the  testicle — because  of  its  superficial  location — the  process 
is  attended  with  additional  discernible  s^'mptoms,  consisting  of  in- 
flammatory edema  of  the  scrotum,  and  a  serosanguineous  effusion  into 
the  tunica  vaginalis. 

The  treatment  of  traumatic  mediate  or  immediate  necrosis  consists 
of  frequent  cleansing  and  disinfection  of  the  part,  and  the  application 
of  aseptic  dry  dressings  with  the  view  of  ohviating  gangrene  and  to 
prevent  contamination  with  putrefactive  organisms.  In  cases  of 
superficial  dry  necrosis  of  the  skin,  moist  dressings  (aluminum  ace- 
tate, boric  acid)  without  rubber  tissue  may  be  used,  on  the  ground 
that  separation  of  the  dead  tissue  is  hastened  by  stimulation  of  granu- 
lation tissue  proliferation. 

Necrosed  organs  (spleen,  gut,  kidney,  testicle)  should  be  promptly 
removed  with  the  view  of  preventing  menacing  inflammations  in  their 
environment  (peritonitis,  scrotal  phlegmon,  etc.). 

In  the  extremities,  formation  of  the  line  of  demarcation  must  be 


NECROSIS  DUE  TO  TRAUMA  525 

awaited  before  amputation  is  executed,  so  that  this  may  not  be  done 
at  an  unnecessarily  remote  point,  nor  at  one  where  the  tissues  are  not 
viable.  When,  however,  gangrene  supervenes  or  when  lymphangitis, 
phlegmon  and  fever  attend  the  putrid  process,  amputation  at  a  point 
remote  from  the  involved  area  must  be  executed,  with  the  view  of 
obviating  general  putrefactive  infection. 

At  the  onset  of  necrosis  of  the  extremities  in  cases  in  which  the 
main  artery  has  been  ligated,  an  effort  should  be  made  to  improve  the 
circulation.  For  the  purpose,  the  dressing  should  be  loosely  applied, 
the  limb  padded  with  cotton,  hyperemic  areas  punctured  and  hemor- 
rhagic infiltrates  and  fluid  transudates  opened  with  the  knife,  in  order 
to  relieve  pressure  on  the  tissues.  When  stasis  follows  ligature  of  a 
vein  or  of  a  vein  and  artery,  elevation  of  the  linih  to  a  vertical  position 
aids  venous  return  and  may  prevent  necrosis  (v.  Bergmann"*). 

To  prevent  necrosis,  Jordan''  and  Dorberauer"  recommend  aiding  the 
gradual  development  of  collateral  circulation  b}"  preliminary  exposure 
of  the  artery  destined  for  ligature,  and  the  application  of  the  liga- 
ture which  is  gradually  tightened  until  complete  occlusion  is  attained 
(in  a  few  days). 

BIBLIOGRAPHY 

1.  EwALD  Wolff.     Beitr.  z.  klin.  Chir.  Bd.  58,  1908. 

2.  Oppel.     Russki  Wratscb,  1913. 

3.  Bakkal.     (Russian)  ref.  in  Zentrbl.  f.  Cbir.  u.  Grenzgeb.  Bd.  3,  1913. 

4.  V.  Bergmaxn.     St.  Petei-sburger  Woeh.,  1877. 

5.  Jordan.     Chir.  kong.  Verb,  ii,  1907. 

G.     DORBERAUER.     Chir.  kong.  Verb,  i,  1908. 


CHAPTER  111 

NECEOSIS  DUE  TO  PEESSUEE,  CONSTEICTIOX,  STRANaULATlON", 

AND    TOESION 

In  this  form  of  necrosis  the  circulation  is  obstructed  by  compression 
of  the  blood  vessels. 

Pressure  Necrosis  {decuhitus). —  This  condition  occurs  most  often 
in  connection  with  wasting  diseases  and  develops  as  the  result  of 
pressure  upon  the  soft  parts  covering  bod}^  projections.  Patients 
confined  to  bed  for  a  long  time  without,  change  of  posture  frequently 
develop  necrosis  in  the  parts  covering  the  sacrum,  the  spinous  pro- 
cesses, and  the  heels.  When  an  inimohilizing  apparatus  is  not  suffi- 
ciently padded  the  process  is  likely  to  occur  at  the  external  edge  of 
the  foot,  the  base  of  the  fifth  metatarsal  bone,  the  heel,  the  anterior 
edge  of  the  tibia,  the  anterior  superior  spinous  process  of  the  ilium, 
and  over  the  patella,  the  trochanter  major,  and  the  chin.  At  times,  it 
occurs  where  the  folds  of  the  skin  come  in  contact  at  apposed  portions 
of  the  iody,  such  as  the  inguinal  region,  between  the  scrotum  and  the 
thigh,  and  between  the  buttocks. 

At  first  the  area  is  painful  but  this  soon  subsides,  unless  inflamma- 
tion is  present.  The  affected  part  takes  on  a  dusky  bluish  hue, 
becomes  numb  and  dry,  and  is  generally  converted  into  a  black,  hard 
crust  which  is  slowly  separated  from  the  surrounding  tissues  by  the 
proliferation  of  gTanulation  tissue.  Because  of  the  debilitated  gen- 
eral condition  of  the  patient  and  the  difficulty  experienced  in  obviat- 
ing the  local  cause,  the  resultant  pressure  ulcer  heals  very  slowly. 
Ulcers  of  this  sort  are  very  liable  to  infection,  especially  when  situated 
over  the  sacrum  where  contamination  with  feces  and  urine  is  likely  to 
occur.  "When  this  happens,  the  process  takes  on  the  form  of  a  putre- 
factive or  pyogenic  infection  (or  these  coexis't)  and  large  areas  of  the 
contiguous  tissues  become  gangrenous,  slough,  destroy  the  fascia,  and 
expose  the  underlying  bone.  In  this  way,  erysipelas,  phlegmon,  and 
severe  general  infection  (often  attended  with  embolic  metastasis  due 
to  pyogenic  thrombosis  at  the  site  of  the  ulcer)  complicate  the  clinical 
picture  and  stand  in  a  causative  relationship  to  a  fatal  outcome. 

526 


NECROSIS  DUE  TO  PRESSURE,  ETC.  527 

In  the  treatment  of  pressure  necrosis,  removal  of  its  cause  is  imper- 
atively indicated.  This  is  much  more  easily  accomplished  when  the 
process  is  due  to  immobilizing  apparatus  than  when  it  occurs  over  the 
sacrum,  especially  when  the  patient  is  very  ill.  The  latter  instance 
heavil}'  taxes  the  ingenuity  of  the  attendants;  however,  much  can  be 
accomplished  by  that  "God  given"  quality,  especially  when  it  is  asso- 
ciated with  patience  and  persistence.  The  patient  should  be  placed 
on  a  water  bed  and  the  posture  changed  at  definitely  indicated  inter- 
vals, the  affected  part  being  protected  from  pressure  by  an  air  cushion 
or  similar  device.  The  necrotic  area  should  be  kept  clean,  covered 
with  dry  dressings,  and  alcohol  should  be  applied  frequently  to  the 
surfaces  adjacent  to  it.  AVet  dressings  should  be  avoided,  as  they 
macerate  the  parts  and  favor  the  dissemination  of  infectious  secretion. 
The  application  of  lint  spread  with  ten  per  cent  zinc  vaselin  lessens 
pain  and  favors  the  proliferation  of  granulations. 

The  prevention  of  pressure  necrosis  is  one  of  the  most  important 
problems  connected  with  the  care  of  the  sick  and  injured,  especially 
following  operations,  the  successful  outcome  of  which  does  not  permit 
of  voluntary  changes  of  posture  on  the  part  of  the  patient.  In  these 
cases,  attention  to  detail  in  the  avoidance  of  pressure,  the  proper 
arrangement  of  attire  and  bed  linen,  frequent  cleansing  of  the  skin, 
the  use  of  the  water  bed,  air  cushions,  etc.,  cannot  be  too  strongly 
insisted  upon. 

In  the  application  of  gypsum,  all  bony  protrusions  and  subcutane- 
ous tendons  should  be  protected  by  pads  of  cotton  wool. 

Constriction  Necrosis. —  Constriction  necrosis  of  the  extremities  fol- 
lows the  faulty  application  of  handages,  or  when  the  v.  Esmarch  ex- 
sanguination  apparatus  has  been  left  m  situ  too  long  (necrosis  has 
followed  when  it  has  been  left  in  place  for  two  and  a  half  hours) .  Of 
dressings,  those  composed  of  gj-psum  are  the  most  dangerous,  espe- 
cially when  they  are  made  to  cover  hematomata  or  are  applied  to 
patients  afflicted  with  arterial  sclerosis.  Under  these  circumstances, 
circulatory^  stasis  rapidly  develops  and  is  soon  followed  by  necrosis  or 
gangrene.  For  this  reason,  the  fingers  and  toes  of  the  bandaged  limb 
should  be  left  exposed  for  purposes  of  observation  in  this  connection. 
If  the  exposed  part  becomes  pale  or  blue,  swollen  or  numb,  the 
apparatus  should  be  removed  at  once  and  carefully  reapplied. 

Infected  wounds  or  inftammatory  processes  should  never  be  covered 
by  gypsum,  as  inflammatorj-  edema  soon  provokes  sufficient  pressure 
to  endanger  the  vitality  of  the  part.     Even  when  this  form  of  dressing 


528  NECROSIS 

is  used  in  cases  in  whicli  infection  has  subsided,  ample  provision 
should  be  made  for  frequent  scrutiny  of  the  site  of  the  wound. 

The  menacing  aspect  of  the  lymphangial  streaks  extending  up  the 
arm  has  induced  patients  to  apply  constriction  above  them  with  the 
result  that  necrosis  of  the  fingers  has  occurred.  The  practice  of  con- 
stricting the  base  of  the  penis  with  a  rubber  band  or  by  the  use  of  a 
wedding  ring  (Lexer^)  for  the  purpose  of  maintaining  an  erection, 
has  resulted  in  necrosis  of  that  organ  in  a  manner  similar  to  that 
following  paraphimosis.  As  a  rule,  the  circulatory  stasis  in  the 
corpora  cavernosa  is  followed  by  gangrene  in  twenty-four  hours. 

Necrosis  of  the  arm  of  the  yiewhorn,  at  times,  follows  a  difficult  labor 
in  which  the  prolapsed  limb  has  been  pressed  by  the  incarcerated  head 
(Fritz  Miiller^). 

Strangulation  Necrosis. —  Strangulation  of  a  loop  of  gut  at  the  her- 
nial outlets  is  promptly  followed  by  circulatory  disturbances  with 
lessening  of  the  resistance  of  the  tissues  against  the  aggression  of  the 
bacteria  which  normally  reside  in  the  mucous  membrane,  and  acute 
gangrene  rapidly  develops. 

Fecal  phlegmon  and  putrefactive  peritonitis  soon  follow,  and,  unless 
promptly  relieved  by  operative  measures,  terminate  fatally. 

Torsion  Necrosis. —  Torsion  of  the  gut,  twisting  (volvulus)  of  a  loop 
of  small  intestine  or  of  the  sigmoid  flexure  (rarely  the  stomach) 
obstructs  the  circulation  and  causes  gangrene.  This  also  occurs  in  the 
ligaments  or  pedicles  of  tumors,  especially  in  ovarian  cysts  and  pedicu- 
lated  uterine  fibroids,  and  has  been  observed  in  the  testicle  when  the 
mesorchium  is  abnormally  long. 

Torsion  is  always  characterized  by  the  rapid  onset  of  the  clinical 
picture;  when  portions  of  the  gut  are  twisted,  the  picture  is  one  of 
ileus.  The  danger  of  complete  gangrene  and  subsequent  peritonitis 
may  be  obviated  only  b}^  prompt  operative  relief  —  either  early  cor- 
rection of  the  faulty  position,  or  resection  of  the  part  and  repair  in 
accord  with  the  conditions. 

The  causation  of  torsion  is  a  much  debated  question.  It  is  believed 
to  be  due  to  the  unequal  growth  of  tumors,  interference  with  their 
growth  in  certain  directions  because  of  anatomical  environment,  and 
to  variation  in  the  blood  pressure  in  the  pedicles  due  to  venous  stasis 
(Payr^). 

BIBLIOGRAPHY 

1.  Lexer.     AWg.   Chir.  Voli,   Stuttgart,   1914. 

2.  Fritz  Mijller.     Strassburg,  1900. 

3.  Patr.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  85,  1906. 


CHAPTER  IV 
NECROSIS    FROM    THERMAL   AND    CHEMICAL   CAUSES 

Thermal  Necrosis. —  Excessive  lieat  and  severe  cold  (plus  63°C. 
—  145.4''F.  and  minus  16°C. —  60.8°F.)  destroy  tissue  in  a  short  time; 
exposure  to  lesser  extremes  of  temperature  for  long  periods  of  time 
accomplishes  the  same  end.  If  necrosis  does  not  supervene  at  once, 
it  follows  disturbances  of  the  circulation  and  the  subsequent  formation 
of  thrombi  (see  Bums  and  Freezing,  Part  IV,  chap.  x). 

The  destructive  action  of  the  Rontgen  and  radium  rays  belongs  in 
this  category.  Persistent  ulcers,  the  result  of  necrotic  destruction  of 
the  skin,  follow  the  prolonged  use  of  these  agents.  The  obliteration 
of  the  blood  vessels  makes  the  proliferation  of  granulations  and  cica- 
trization an  exceedingly  indolent  process. 

A  number  of  chemical  agents  are  capable  of  producing  necrosis. 

Chemical  Necrosis. —  All  caustic  acids  and  alkalies  destroy  tissue  hy 
a  process  of  dehydration,  by  chemical  combination  with  the  cell  proto- 
plasm, or  by  disturbing  the  circulation.  Diluted  chemicals,  such  as 
are  used  for  disinfection,  may  have  deleterious  effects,  especially  in 
situations  denuded  of  epidermis ;  when  inflammatory  stasis  is  present ; 
or  in  cases  of  general  debility  and  consequent  lessening  of  local 
resistance. 

This  is  well  illustrated  in  connection  with  the  use  of  carbolic  acid. 
Although  this  agent  has  practically  disappeared  from  the  armamen- 
tarium of  the  surgeon,  the  laity  still  use  it  for  the  purpose  of  "heal- 
ing" superficial  wounds,  espccialh^  of  the  fingers  and  toes,  with  gan- 
grene {carbolic  acid  gangrene)  as  a  not  infrequent  result.  This  form 
of  gangrene,  at  times,  follows  twenty-four  hours*  continuous  use  of  a 
one  per  cent  solution. 

The  destructive  action  of  carbolic  acid  is  not  specific  (Rosenberger,^ 
Honsell,^  and  others)  but  is  caused  by  injury  to  the  circulation  similar 
to  that  produced  b}'  dilute  caustic  chemicals.  The  solution  dehydrates 
the  superficial  la^'ers  of  the  epithelium  and  of  the  tissues,  penetrates 
between  the  contracted  cells  and  causes  dilatation  of  the  blood  vessels. 

529 


530  NECROSIS 

The  result  is  a  slowing  and  stasis  of  the  flow  of  blood  which  interferes 
with  nutrition,  arrests  absorption,  and  favors  the  accumulation  of  the 
poison.  Thrombosis  does  not  cause  necrosis  (Frankenburgcr^)  but  is 
its  result.  Roseuberger^  seems  to  have  shown  that  carbolic  acid  delays 
coagulation  of  the  blood. 

Lysol  and  alcohol  act  in  a  similar,  but  more  moderate,  manner.  The 
latter,  when  confined  by  impermeable  dressings  (rubber  tissue),  may 
convert  the  entire  area  of  its  application  into  a  dry  black  crust. 

Normal  secretions  and  excretions,  when  brought  in  contact  with  tis- 
sues denuded  of  their  protecting  epithelium,  are  capable  of  destroying 
them.  This  is  seen  in  cases  of  gastric  fistulse,  where  the  gastric  juice 
comes  directly  in  contact  with  the  raw  surfaces  of  wounds  and  causes 
the  development  of  phagedenous  ulcers  which,  at  times,  are  very  exten- 
sive. This  no  doubt  also  accounts  for  the  formation  of  gastric  ulcers, 
which  result  from  the  digestion  of  the  gastric  mucosa  in  areas  from 
which  the  circulation  is.  cut  off  by  thrombi  or  thrombo-embolic 
processes  (Payr*), 

Leakage  of  pancreatic  juice,  following  injury  or  disease  of  the 
pancreas,  results  in  necrosis  of  the  fatty  tissue  of  the  omentum,  of  the 
posterior  wall  of  the  abdomen,  and  of  the  portions  of  the  gut  with 
which  it  comes  in  contact.  The  process  is  attended  by  the  decomposi- 
tion of  fat  into  fatty  acids  and  glycerin,  the  former  combining  with 
calcium  salts  to  form  the  yellowish  nodules  characteristic  of  fat 
necrosis. 

Extravasation  of  urine  is  followed  by  extensive  necrosis,  which, 
when  complicated  by  bacterial  invasion,  results  in  severe  putrefactive 
infection. 

A  similar  process  attends  the  leakage  of  feces  into  the  tissues. 

The  bacterial  toxins  coincident  to  inflammation  also  exercise  a 
destructive  action  upon  tissue  which,  in  rapidly  extending  processes, 
takes  on  the  form  of  necrosis  or  gangrene,  while  in  the  milder  forms 
of  infection  in  which  the  leukocytes  destroy  the  tissues  more  slowly, 
they  are  cast  off  in  the  form  of  pus.  To  this  must  be  added  the 
destruction  of  tissue,  the  result  of  their  exclusion  from  the  circulation 
by  the  formation  of  inflammatory  thrombi. 

BIBLIOGRAPHY 

1.  RosENBERGER.     Wiirzhurgr,  Stuber,  1901,  with  lit. 

2.  HoNSELL.     Beitr.  z.  klin.  Chir. 

3.  Frankenburger.     Erlan,e;en,  1891. 

4.  Payr.     Deutsch,  Chir.  Kong.  Verb,  ii,  1907. 


CHAPTER  V 

NECEOSIS    FROM   EMBOLISM   AND    THROMBOSIS 

Necrosis  is  caused  by  embolism  or  thronihosis  in  the  arterial  system, 
but  by  thrombosis  only  in  the  venous  system. 

Necrosis  from  Embolism. —  Emboli  usually  originate  in  a  portion  of 
the  carriers  of  the  circulatory  fluid  central  to  the  bifurcation  of  the 
aorta,  in  the  left  heart  and  occasionally  (when  the  foramen  ovale  is 
patent)  in  the  right  heart.  Sclerosis  and  .syphilis  of  arteries,  arteritis 
purule7ita,  in  conjunction  with  local  and  general  pyogenic  processes, 
aneurisms  and  traumatized  vessels  whose  walls  are  the  seat  of  thrombi, 
form  the  bases  from  which  emboli  are  detached.  In  the  heart,  myo- 
carditis, and  more  especially  endocarditis  developing  in  the  course  of 
acute  infectious  diseases,  of  which  typhoid  fever,  variola,  and  scarla- 
tina are  the  most  frequent,  are  a  fruitful  source  of  embolism. 

Arterial  embolic  occlusion  and  necrosis  occur  most  often  in  the 
extremities  and  in  the  gut. 

Embolism  of  the  mesenteric  arteries,  because  of  the  intestinal  paraly- 
sis it  provokes,  presents  a  clinical  picture  of  ileus ;  it  is  characterized 
by  its  sudden  onset,  by  shock,  and,  at  times,  by  hemorrhagic  .stools. 
Gangrene  and  peritonitis  soon  develop  and  cause  death.  It  is  fre- 
quently mistaken  for  intestinal  strangulation  or  volvulus. 

Of  the  arteries  of  the  extremities,  the  popliteal  is  most  often 
occluded.  The  lodgment  of  the  emboli  is  attended  with  sudden, 
severe,  persistent  pain  in  the  affected  limb,  the  skin  of  which  becomes 
cold  and  pale  or  of  a  mottled  cyanotic  hue.  After  the  lapse  of  a  few 
hours,  motor  and  sensory  paralyses  develop,  though  referred  pain  still 
persists.  At  the  site  of  the  embolus  the  artery  is  tender ;  below  this 
there  is  no  pulsation. 

The  subsequent  course  of  the  process  varies.  When  the  artery  is 
completely  occluded,  the  fate  of  the  distal  part  is  dependent  upon  the 
extent  of  the  collateral  circulation,  the  efficient  development  of  which 
is  usually  hampered  by  coexisting  cardiac  insufficiency,  general  arterial 
disease,  the  early  formation  of  a  central  thrombus,  and,  in  cases  in 
which  the  embolus  is  of  the  infected  variety,   the  development  of 

531 


532  NECROSIS 

bacterial  inflammatioii.  In  moderate  cases  the  part  is  edematous  and 
hyperemic  for  a  long  time  (due  to  dilatation  of  the  capillaries  and 
small  veins),  which,  together  with  the  attendant  paralj^sis,  gradually 
disappears.  In  a  number  of  instances,  however,  interruption  of  the 
arterial  circulation  is  followed  hy  necrosis  of  the  terminal  portion  of 
the  limb  which  in  a  few  days  extends  to  its  line  of  demarcation. 

When  the  occlusion  is  primarily  incomplete  and  becomes  complete 
as  the  outcome  of  the  deposit  of  fibrin,  the  excluded  part  presents  a 
bluish  red  appearance,  is  soon  covered  with  necrotic  blebs,  and  is 
distended  by  an  ecchymotic  edema. 

Mummification  is  usually  restricted  to  fingers  and  toes ;  the  soft 
parts  near  the  line  of  demarcation  soon  become  gangrenous  and, 
despite  aseptic  precautions,  often  develop  putrefactive  thrombo- 
phlebitis and  general  infection. 

The  outlook  in  embolic  necrosis  of  the  extremities  is  not  favorable. 
This  does  not  pertain  to  the  local  condition  alone,  but  also  to  the 
underlying  cause,  which  of  itself  offers  reason  for  a  grave  prognosis, 
and  not  infrequently  involves  the  danger  of  additional  embolism. 

Arterial  Thrombotic  Necrosis. —  Arterial  thromhosis  causes  gangrene 
of  the  extremities  when  the  vessel  is  completely  obstructed  by  the 
deposit  of  fibrin  —  as  the  result  of  the  presence  of  an  aneurism,  injury 
to  the  intima  b}^  crushing,  pressure  of  a  tumor,  or  by  an  acute  or 
chronic  arteritis.  A  causative  acute  arterial  inflammation  often 
occurs  in  the  course  of  typhoid  fever  and,  at  times,  though  rarel}^  in 
pyogenic  general  infections;  or  in  acute  infectious  diseases  in  which 
bacteria  gain  access  to  the  artery  through  the  vasa  vasorum. 

This  aspect  of  the  situation  is  not  as  menacing  as  is  embolic  necrosis. 
The  gradual  diminution  of  the  circulation  gives  opportunity  for  the 
development  of  collateral  flow  of  blood,  provided  the  anastomotic 
vessels  are  not  sclerotic.  The  quantit}^  of  blood  in  the  affected 
extremity  is  never  small  enough  to  provoke  the  picture  of  ischemia. 

The  danger  in  these  cases  also  lies  in  the  underlying  causative 
general  condition. 

Differentiation  between  arterial  thrombosis  and  incomplete  embolism 
is  clinically  impossible.  In  contrast  to  necrosis  from  chronic  blood 
vessel  disease,  the  comparatively  rapid  development  of  the  process; 
when  due  to  occlusion  of  an  artery,  is  of  diagnostic  importance. 

Since  the  causes^  appearance  and  treatment  of  venous  thrombotic 
gangrene  are  identical  with  those  of  arterial  origin  it  is  not  necessary 
to  consider  them  separately. 


NECROSIS  FROM  EMBOLISM  AND  THROMBOSIS      533 

The  treatment  of  embolic  and  thrombotic  gangrene  is  subject  to  the 
same  rules  that  govern  it  in  connection  with  necrosis  following  ligature 
of  main  arteries.  The  formation  of  the  line  of  demarcation  should  be 
awaited;  however,  if  the  gravity  of  the  underlying  causative  con- 
ditions or  the  development  of  putrid  infection  renders  a  policy  of 
expectancy  dangerous,  high  amputation  should  be  immediately 
executed  (Part  V,  chapter  iv). 


CHAPTER  VI 

NECROSIS   DUE    TO    CHRONIC   DISEASES    OF   BLOOD    VESSELS 

Pathological  dilation  mid  narrowing  of  arteries  and  veins  cause 
circulatory  disturbances  which,  result  in  necrosis  of  the  distal  portions 
of  the  extremities. 

Necrosis  from  Chronic  Diseases  of  Arteries. —  True  and  arteriovenous 
aneurisms  rarely  cause  necrosis  unless  thrombosis  or  embolism  coexist, 
although  the  disturbances  of  circulation  they  provoke  are  frequently 
manifested  by  the  presence  of  neuroses  and  chronic  skin  eruptions  in 
the  distal  portions  of  the  body.  On  the  other  hand,  mummification  of 
the  fingers  often  occurs  in  connection  with  hemangioma  racemosum 
of  the  forearm. 

The  most  frequent  cause  of  necrosis  is  the  reduction  of  the  caliber 
of  the  arteries  —  either  of  a  number  of  vessels  in  a  zone,  or  of  the 
main  vessel  itself  —  by  the  proliferation  of  the  intima,  which  favors 
the  formation  of  thrombi  and  ultimately  leads  to  their  complete 
occlusion.  The  process  in  the  intima  is  the  result  of  arteriosclerosis 
or  endarteritis  syphilitica. 

Angiosclerotic  Necrosis. —  Arterio-  or  angiosclerotic  necrosis  in  the 
aged  is  called  senile  necrosis,  when  it  occurs  in  youth  or  early  middle 
age  it  is  called  presenile  necrosis. 

This  form  of  necrosis  occurs  chiefly  in  men  and  usually  involves  the 
terminal  portions  of  the  extremities.  It  involvesi  the  foot  more  often 
than  the  hand,  but  may  appear  simultaneously  in  both  feet  or  may 
occur  in  sequence  first  in  one  foot  and  then  in  the  other,  and  has  been 
known  to  attack  both  the  feet  and  hands  at  the  same  time.  It  appears 
gradually  (never  suddenly)  and  for  years  is  preceded  by  sensations 
of  cold,  numbness  and  distressing  neuralgic  or  rheumatic  pain  — 
especially  in  the  legs  after  walking  —  and  by  bluish  discolorations  of 
the  feet  and  hands.  The  relative  frequency  of  this  form  of  necrosis 
in  the  lower  extremities  is  explained  by  the  unfavorable  circulatory 
conditions  and  the  frequency  with  which  they  are  unavoidably 
traumatized. 

534 


NECKOSIS  DUE  TO  DISEASES  OF  BLOOD  VESSELS    535 

The  heginning  of  necrosis  is  usually  heralded  by  the  appearance  of 
a  bluish  black  spot  at  the  tip  of  a  toe  or  finger.  The  onset  may  be 
spontaneous ;  or  it  may  be  associated  with  trauma,  such  as  the  paring 
of  a  corn,  a  slight  contusion,  or  the  pressure  of  a  tight  boot ;  or  it  may 
develop  in  connection  with  an  inflammation,  exposure  to  cold  or  the 
use  of  carbolic  acid  solution.  The  process  appears  as  dry  necrosis  or 
gangrene.  In  the  latter  instance,  it  is  usually  associated  with  phleg- 
mon or  lymphangitis,  and  the  process  either  restricts  itself  to  the  area 
involved  or  spreads  over  more  or  less  of  the  limb.  In  some  cases  all 
the  fingers  and  toes  become  mummified,  are  separated  from  the  limb, 
and  the  resultant  ulcerating  surfaces  cicatrize. 

The  development  of  senile  necrosis  is  always  associated  with  cardiac 
insufficiency  and  arteriosclerosis,  and  in  most  instances  the  veins  also 
are  involved.  In  cases  of  angiosclerosis,  associated  with  calcareous 
deposits,  the  process  may  be  demonstrated  by  means  of  the  radiogram. 
However,  the  immediate  exciting  cause  of  the  necrosis  is  not  always 
the  same ;  it  may  be  due  to  the  underl^'ing  lessening  of  the  circulation, 
or  to  an  external  injury  which  causes  thrombosis  of  the  capillaries  and 
smaller  hlood  vessels;  or  an  occluding  thrombosis  may  develop  in  con- 
nection with  an  atheromatous  ulceration  of  the  intima  of  a  large 
artery.  As  the  collateral  circulation  is  hampered  by  proliferative 
obliteration  and  the  formation  of  thrombi,  it  is  of  course  not  sufficient 
to  obviate  the  occurrence  of  the  necrosis. 

In  presenile  necrosis,  cardiac  insufficiency  is  not  a  factor.  This 
form  of  the  affliction  consists  of  the  obliteration  of  large  zones  of  the 
arteries,  due  in  part  to  occluding  proliferation  of  the  intima,  and  in 
part  to  the  formation  of  thrombi  which  either  obstruct  the  small 
sclerotic  arteries  or  are  deposited  in  the  larger  vessels,  especially  where 
lateral  branches  are  given  off.  These  thrombi  are  often  multiple  and, 
in  cases  of  insular  or  general  arteriosclerosis,  grow  by  the  additional 
deposit  of  fibrin  which  extends  the  obstruction  toward  the  heart,  pro- 
gressively abolishing  collateral  circulation  (Zoge  v.  Manteuffel/ 
Bunge,^  etc.).  The  excessive  use  of  tobacco  and  alcohol  are  regarded 
as  favoring  the  development  of  the  arteriosclerotic  condition  which 
underlies  this  form  of  necrosis.  Of  the  exciting  causes,  exposure  to 
cold  is  regarded  as  the  most  important  factor  (Zoge  v.  ManteuffeP). 
RudnitzkiV  animal  experimentation  seems  to  show  that  proliferative 
endarteritis  follows  repeated  chilling  of  the  extremities. 

Vasomotor  disturbances  are  also  believed  to  stand  in  a  causative 
relationship  to  presenile  necrosis  ("Wulff,*  and  Higier^). 


536  NECROSIS 

The  diagnosis  of  angiosclerotic  necrosis  should  not  be  based  on  the 
fact  that  degeneration  of  the  blood  vessels  is  present,  as  this  is  a 
widely  disseminated  affliction  and  is  not  by  any  means  alwaj^s  attended 
with  necrosis.  In  all  instances,  the  existence  of  diabetes,  nervous 
afflictions,  and  sypJiilis  should  he  excluded. 

The  treatment  is  directed  toward  the  prevention  of  infection,  by  the 
application  of  dry  aseptic  dressings  and  the  prompt  removal  of 
necrotic  areas.  "When  tissues  are  mummified,  their  separation  may  be 
hastened  by  the  application  of  aluminum  acetate  solution  (without 
rubber  tissue).  The  use  of  alcohol,  carbolic  acid,  and  agents  which 
of  themselves  are  liable  to  destroy  tissue  must  be  avoided. 

Phlegmonous  inflammation  should  be  promptly  incised ;  when,  how- 
ever, this  measure  is  not  followed  by  recession  of  the  infection,  ampu- 
tation must  be  resorted  to  without  delay.  As  necrosis  of  the  stump 
often  follows  the  use  of  v.  Esmarch's  exsanguination  during  the 
operation,  its  employment  is  of  doubtful  utility.  The  amputation 
must  be  executed  some  distance  central  to  the  area  of  necrosis,  i.  e., 
when  the  leg  is  involved  the  section  should  be  carried  through  the 
thigh,  etc.  Refinements  in  the  formation  of  flaps,  such  as  the  use  of 
sections  of  bone,  are  not  suitable  in  cases  of  this  sort.  The  flaps 
should  be  ample  and  the  operative  technic  rapidly  executed.  When 
cardiac  insufficienc}"  or  nephritis,  or  both,  complicate  the  problem, 
local  or  spinal  anesthesia  may  be  employed. 

In  the  early  stages  of  the  disease,  when  venous  stasis  is  present, 
incision  of  the  necrotic  area  on  the  fingers  and  toes,  and  the  subsequent 
use  of  suction  by  means  of  especially  devised  glass  bulbs,  with  the 
view  of  increasing  the  circulation,  are  measures  worthy  of  employment 
(Nosske^), 

The  question  as  to  how  high  up  amputation  should  be  performed  is 
not  always  easilj^  answered.  Moszkowicz"  suggests  being  guided  by 
the  dilatation  of  the  superficial  blood  vessels  that  follows  the  use  of 
V.  Esmarch's  exsanguination.  Exsanguination  of  the  limb  is  main- 
tained for  five  minutes,  at  the  end  of  which  time  redness  of  the  skin 
denotes  the  level  to  which  the  circulation  is  still  good.  In  some  cases, 
the  border  of  redness  is  indistinct  and  A^ry  broad,  or  the  entire  limb 
exhibits  a  faint  pink  color,  in  which  event,  reliance  must  be  placed  on 
the  absence  of  pulsation  (Bergemann^). 

Wieting^  connected  the  femoral  artery,  below  the  profunda,  with 
the  femoral  vein  peripheral  to  the  saphenous,  b}^  circular  anastomosis, 
so  that  the  arterial  blood  flowed  into  the  vein  by  overcoming  the 


NECROSIS  DUE  TO  DISEASES  OF  BLOOD  VESSELS     537 

meager  valvular  resistance  of  the  latter.  In  appropriate  cases 
(absence  of  inflammation,  gangrene,  and  thrombosis),  the  circulation 
in  the  limb  is  improved  and  beginning  necrosis  does  not  extend 
(Wieting,"  Glasstein,^^  Conen^^). 

Diabetic  Gangrene. —  This  variety  bears  considerable  resemblance 
to  the  angiosclerotic  form.  However,  in  diabetes,  the  changes  in  the 
blood  vessels  are  more  rapid  and  are  attended  with  the  formation  of 
thrombi  in  the  larger  and  smaller  arteries  and  veins,  a  condition  of 
affairs  markedly  increasing  the  susceptibility  of  the  tissues  to  pyogenic 
and  putrid  infections,  which  may  take  on  very  severe  forms  and  cau::e 
extensive  destruction  of  tissue. 

The  experimental  work  of  Grossmann^^  and  Hildebrandt^*  has 
shown  that  bacteria  multiply  and  gain  in  pathogenicity  much  more 
rapidly  in  tissues  containing  glucose  than  in  normal  tissue.  For 
instance,  the  injection  of  a  streptococcus  culture  into  an  animal  arti- 
ficially made  diabetic  is  followed  by  the  development  of  inflammation 
and  the  formation  of  a  large  ulcerating  infiltrate,  while  the  same 
dosage  introduced  into  a  normal  animal  is  not  followed  by  any 
disturbances. 

To  this  must  be  added  the  reduced  resistance  of  diabetic  tissue  to 
infection,  which  is  shown  by  its  rapid  necrotic  disintegration  sequential 
to  infections  ordinarily  attended  with  a  moderate  degree  of  inflam- 
mation and  suppuration. 

Therefore  the  clinical  picture  of  diabetic  gangrene  encompasses  the 
manifestations  of  inflammation  to  a  greater  degree  than  the  other 
forms  of  tissue  destruction.  Diabetic  gangrene  often  begins,  like  the 
angiosclerotic  form,  with  necrosis  of  the  skin  (preceded  by  the  usual 
prodroma)  and,  at  times,  mummification  occurs,  but  the  process  soon 
becomes  inflammatory  and  gangrene  develops.  At  other  times,  the 
process  is  primarily  an  inflammation  which  soon  merges  into  gangrene. 
It  begins  at  the  site  of  a  slight  injurj^,  such  as  occurs  in  the  paring 
of  a  corn  or  where  pressure  has  been  made  by  a  boot,  or  it  develops  at 
the  site  of  a  small  abrasion"  or  where  the  skin  is  cracked  at  the  heel,  the 
sole  of  the  foot  or  the  palm  of  the  hand. 

Diabetic  gangrene  rarely  forms  a  line  of  demarcation  nor  is  it  fol- 
lowed by  separation  of  the  dead  tissue  and  healing ;  on  the  contrary, 
the  attendant  inflammation  causes  it  to  extend  more  rapidly  than  the 
senile  form  and  to  destroy  large  portions  of  the  foot  and  leg. 

The  dangers  of  diabetic  gangrene  do  not  lie  alone  in  its  rapid 
extension  and  likelihood  of  concomitant  pyogenic  or  putrefactive  local 


538  NECKOSIS 

and  general  infections,  but  also  in  the  coexisting  cardiac  insufficiency, 
primarily  the  result  of  arterial  sclerosis  and  fever,  which  latter  soon 
leads  to  grave  systemic  disturbances  (vomiting,  restlessness,  and  head- 
ache), ultimately  succeeded  by  unconsciousness,  delirium,  collapse, 
coma,  and  death.  This  outcome  often  follows  the  administration  of  a 
general  narcotic  and  an  operative  effort  at  relief  from  an  infected, 
diabetic,  gangrenous  process  of  several  weeks'  standing;  however,  the 
psychic  disturbances  attendant  upon  the  execution  of  the  operation 
under  local  anesthesia  also  frequently  lead  to  a  fatal  result. 

The  treatment  (aside  from  the  antidiabetic  measures)  is  directed 
toward  limiting  the  extent  of  gangrene  and  the  prevention  of  infec- 
tion. The  affected  part  should  be  elevated  and  immoMlized  with  the 
view  of  aiding  the  circulation. 

The  rare  dry  form  of  necrosis  is  treated  in  the  same  way  as  is  the 
senile  form,  except  that  wet  dressings,  because  of  the  danger  of  putre- 
faction, must  be  avoided.  Alcohol  and  hydrogen  peroxid  may  be  used 
for  cleansing  purposes. 

When  ga7igrenous  phlegmon  develops,  and  the  general  condition  of 
the  patient  justifies  the  attempt,  the  infected  area  may  he  freely 
incised,  especially  when  acidosis  is  absent  (Klemperer^^).  In  a  cer- 
tain number  of  cases,  this  measure,  together  with  antidiabetic  diet, 
dry  dressings  (except  in  mummification),  elevation,  and  immobiliza- 
tion of  the  part  is  followed  by  demarcation  of  the  process  and  healing. 
Epidermis  loosened  by  suppuration  should  be  carefully  removed. 

When,  however,  these  measures  do  not  attain  the  desired  result,  and 
the  gangrenous  process  extends,  the  fever  does  not  diminish,  the  sugar 
content  of  the  urine  increases,  and  the  strength  of  the  patient  fails, 
and  when  cardiac  insufficiency  and  the  prodroma  of  impending  coma 
begin  to  be  manifested,  amputation  becomes  imperative,  and,  indeed, 
results  in  a  favorable  outcome  in  about  sixty  per  cent  of  the  cases 
(Grossmann^^). 

The  SELECTION  OF  THE  POINT  OF  AMPUTATION  DEPENDS  UPON  THE 
EXTENT   OF   THE  INFLAMMATION  AND  THE  DEGREE  OF   ARTERIAL  DISEASE. 

When  phlegmon  has  involved  the  leg  and  the  popliteal  artery  is  hard, 
cord-like,  and  pulseless,  amputation  should  be  executed  at  the  thigh 
(supracondyloid).  In  cases  of  lesser  degree,  the  section  may  be 
made  through  the  leg.  In  cases  of  dry,  demarcating  necrosis,  the 
methods  of  Syme,  Pirogoff  or  Chopart  may  be  employed.  When  the 
pulse  is  discernible  in  the  dorsalis  pedis,  exariiculation  of  the  affected 
toe  or  toes  may  suffice. 


NECROSIS  DUE  TO  DISEASES  OF  BLOOD  VESSELS     539 

"When  the  process  is  rapidly  extending,  reamputation  at  a  higher 
point  may  be  necessary. 

The  operation  should  he  performed  with  the  greatest  possible  sim- 
plicity and  under  strict  asepsis.  Manipulations  of  the  parts  with  the 
fingers  should  be  avoided.  V.  Esmarch's  exsanguination,  if  used, 
should  be  maintained  for  as  short  a  period  as  is  possible.  Man}-  sur- 
geons amputate  under  digital  compression  of  the  main  artery,  though, 
in  cases  of  general  debility,  the  careful  application  and  the  prompt 
removal  of  the  rubber  constriction  is  a  lesser  evil  than  the  loss  of  blood 
entailed  by  its  omission. 

General  narcosis  in  cases  of  diabetes  is  objectionable  and,  if  em- 
ployed, should  be  as  brief  as  possible,  as  it  is  followed  by  increased 
glycosuria  and  acetmiuria  and,  in  some  cases,  by  coma.  The  admin- 
istration of  chloroform  or  ether  (especially  the  former)  to  non- 
diabetics,  is  often  followed  by  moderate  acetonuria  and,  at  times,  by 
glycosuria. 

The  use  of  local  anesthesia  is  also  not  devoid  of  danger,  first,  because 
infiltration  of  the  tissues  increases  the  tendenci)  to  gangrene,  and, 
second,  because  the  manipulation  necessary  to  its  accomplishment 
favors  infection  and  often  excites  the  patient  to  a  degree  provocative 
of  collapse  or  coma.     Lumbar  anesthesia  is  not  alwa^'s  well  borne. 

The  clinical  experience,  that  the  mental  excitement  before  and  after 
operation  has  a  more  important  bearing  upon  the  increase  of  glyco- 
suria than  has  narcosis  itself,  would  seem  to  be  substantiated  by  the 
experimental  work  of  Jacobsen^®  in  connection  with  ''fright  hyper- 
glycemia. ' ' 

Following  amputation,  recession  of  the  fever  and  lessening  of  glyco- 
suria are  favorable  signs.  "When  coma  is  established,  the  outlook  is 
hopeless. 

The  occurrence  of  diabetic  coma  is  ascribed  to  an  intoxication  by 
abnormal  acids  (especially  oxybutyric),  the  result  of  disturbed  meta- 
bolic processes.  When  this  occurs  the  blood  is  no  longer  capable  of 
forming  a  chemical  union  with  the  carbon  dioxid  in  the  tissues  or  of 
removing  it.  Acting  on  this  theory,  attempts  have  been  made  to 
prevent  the  excessive  accumulation  of  these  acids  by  the  liberal  admin- 
istration of  alkalies.  For  the  purpose,  large  doses  of  sodium  bicar- 
bonate are  administered  by  the  mouth,  or  a  three  to  five  per  cent 
solution  may  be  introduced  intravenously.  With  this  in  view,  opera- 
tions on  diabetics  have  been  preceded  by  the  administration  of  large 


540  NECROSIS 

doses  of  the  remedy  (150  gm.  in  twenty-four  hours),  and,  in  eases  of 
threatened  coma,  the  same  agent  has  been  used  (Kausch^'^). 

Syphilitic  Gangrene. —  Syphilitic  gangrene  of  the  extremities  fol- 
lows pathological  changes  of  large  and  small  arteries ;  it  begins  as  an 
endarteritis  syphilitica,  is  succeeded  by  occluding  thrombosis  of  their 
lumen,  and  occurs  in  the  congenital  and  acquired  forms  of  the  disease. 

The  frequency  of  its  occurrence  is  not  easily  determined,  since  it  is 
likely  to  be  confused  with  other  forms  of  necrosis  of  the  extremities, 
especially  the  presenile  form  of  angiosclerotic  gangrene.  Young  and 
middle  aged  men  are  attacked  by  the  disease  more  often  than  women. 

Clinically,  luetic  necrosis  presents  no  differences  from  the  angio- 
sclerotic form  of  youth.  The  prodroma  are  the  same  and  the  local 
lesion  takes  on  the  form  of  mummification,  or  of  gangrene  of  the 
fingers  and  toes,  is  usually  circumscrihed  and  demarcated,  or  is 
attended  with  phlegmonous  inflammation.  In  some  instances,  the 
necrosis  is  multiple  and  may  be  symmetrical,  involving  both  hands  and 
feet  (Elsenbcrg^^).  Separation  of  the  necrotic  areas  is  followed  by 
persistent  ulceration.  The  large  arteries  are  hard,  pulseless  cords, 
in  the  course  of  which  nodular  areas  of  thickening  may,  at  times,  be 
palpated. 

Necrosis  of  the  fingers  and  toes  in  young  persons  (before  thirty-t 
five)  following  protracted  circulatory  disturbances,  should  arouse  sus- 
picion of  a  syphilitic  etiology,  especially  in  the  presence  of  other 
evidence  of  congenital  or  acquired  lues.  The  diagnosis  rests  on  the 
improvement  of  circulatory  disturbances  after  antisyphilitic  treat- 
ment ;  on  the  microscopical  examination  of  removed  parts,  and  on  the 
serodiagnostic  findings. 

The  treatment  consists  in  the  administration  of  mercury,  iodin,  and 
salvarsan,  and  the  exercise  of  the  rules  laid  down  in  connection  with 
the  local  treatment  of  angiosclerotic  necrosis. 

Venous  Dilatation. —  Disturbances  of  the  circulation,  the  result  of 
dilatation  of  the  veins,  occur  in  the  legs  very  frequently. 

Slowing  of  venous  return,  the  outcome  of  valvular  insufficiency  in 
dilated  veins  of  the  leg,  of  itself,  is  not  responsible  for  the  necrotic 
disintegration  of  the  skin  so  frequently  observed  in  this  situation.  It 
does,  however,  reduce  the  nutrition  in  the  skin  in  the  region  of  the 
lower  leg,  thus  lessening  its  regenerative  capacity  to  overcome  the 
destructive  action  of  trauma,  especially  when  this  is  complicated  by 
infection.  Repeated  processes  of  this  sort  ultimately  result  in  the 
formation  of  the,  so-called,  ulcus  cruris  varicosum,  commonly  known 


NECROSIS  DUE  TO  DISEASES  OF  BLOOD  VESSELS     541 

as  chronic  ulcer  of  the  leg,  usually  found  associated  with  phlebectasis 

(Fig.- 185). 

Where  the  circulatory  conditions  favor  necrosis,  the  infliction  of 
trauma  in  the  form  of  superficial  abrasions,  contusion  of  the  skin  and 
subcutaneous  tissues  with  extravasation  of  blood,  and  in  locations 
where  the  skin  is  already  atrophic  from  the  pressure  of  a  varix,  or 
where  a  suppurating  thrombus  has  ruptured,  or  where  the  hyperemia 
of  a  furuncle  increases  the  embarrassment  of  the  circulation,  the 
superficial  or  deep  disintegration  of  the  skin  is  followed  by  the  forma- 
tion of  a  characteristic  ulcer. 

The  persistence  of  the  ulcerative  process,  its  slow  repair,  and  the 
frequent  relapses  after  cicatrization,  are  contributed  to  by  main- 
tenance OF  THE  ERECT  POSITION,  AS  IN  OCCUPATIONS  WHICH  REQUIRE 
THE  PATIENT  TO  STAND  OR  WALK  FOR   MANY  HOURS  AT  A  TIME.      Under 

these  conditions,  the  engorged  smaller  veins  are  likely  to  transude 
blood  into  the  ulcerated  area,  or  it  infiltrates  the  newly  formed  scar 
tissue  and  leads  to  renewed  ulceration.  In  addition  to  this,  the  con- 
stant I3'  immigrating  bacteria  find  the  conditions  exceedingly  favorable 
to  multiplication,  and  consequent  development  of  infection  and  exten- 
sive gangrenous  destruction  of  tissue  results.  This  destruction  is  the 
outcome  of  the  action  of  bacterial  toxins  and  of  the  inflammatory 
hyperemia  which  produces  stasis  in  the  poorly  nourished  tissues,  and 
is  attended  with  the  formation  of  inflammatory  venous  thrombosis. 
In  many  instances  the  situation  is  complicated  b}^  acute  progressive 
inflammatory  processes,  such  as  erj^sipelas,  Ijonphangitis,  and  thrombo- 
phlebitis, all  of  which  are  likely  to  be  attended  with  the  formation  of 
venous  thrombi  that  obstruct  the  return  flow  of  blood.  When  the 
process  is  extensive  and  accompanied  by  the  formation  of  large  cica- 
trices, the  contraction  of  the  proliferated  connective  tissue  causes  the 
skin  to  become  adherent  to  the  bone,  forming  an  immovable  zone  of 
constriction  which  still  more  obstructs  the  circulation  in  the  distal 
portion  of  the  limb,  thus  causing  a  state  of  chronic  edema  which 
ultimately  takes  on  the  form  erf  acquired  elephantiasis  (Fig,  185). 

All  or  a  part  of  these  influences  exist  to  a  greater  or  lesser  extent  in 
individual  cases,  and  are  most  menacing  when  associated  with  general 
arteriosclerosis  or  with  great  dehility. 
•    Varicose  ulcers  are  most  often  located  on  the  anterior  inner 

SURFACE  OF  THE  LOWER  THIRD  OF  THE  LEG  AND  0\'T:R  THE  INNER  MAL- 
LEOLUS, i.  e.,  in  the  zone  of  origin  of  the  large  saphenous  vein.  The 
area  of  origin  of  the  small  saphenous  vein  is  less  often  involved.    Both 


542 


NECROSIS 


legs  are  not  infrequently  invaded,  or  one  leg  presents  the  stage  of 
ulceration  while  the  other  exhibits  the  prodroma,  such  as  obstinate 
scaly  eczema,  or  its  sequels  in  the  form  of  dark,  brown  pigmentation, 
the  result  of  residual  coloring  matter  of  the  blood. 

Small  ulcers  always  develop  in  conjunction  with  phlebectases, 
though  they  rarely  appear  before  the  fortieth  year  of  life.  The  larger 
ulcers  are  often  seen  in  the  poorer  elasses  where  hard  work  and  lack 
of  cleanliness  are  dominant. 


Pig.  185. —  Varicose  Ulcer  of  the  Leg. 

The  appearance  of  the  ulcer  (Fig.  18'5)  varies;  however,  it  differs 
sufficiently  from  syphilitic  and  carcinomatous  processes  to  be  readily 
distinguished.  Its  borders  are  irregular  —  not  undermined,  shallow 
or  irregularly  thickened  and  hard.  The  base  of  the  ulcer  is  flat  (when 
the  edges  are  thickened,  it  may  be  deep  in  the  center),  yellow,  and 
covered  with  sloughs  or  granulations  which,  though  rarely  healthy,  are 
exuberant,  soft,  flabby,  and,  because  of  frequent  rupture,  are  speckled 
or  bluish  in  color.     The  exudate  is  abundant  in  quantity  and  seropuru- 


NECROSIS  DUE  TO  DISEASES  OF  BLOOD  VESSELS     543 

lent  or  putrid  in  character.  As  the  ulcerating  area  is  usually  adherent 
to  the  bone,  it  is  immovable.  It  is  surrounded  by  a  zone  of  pigmented 
scar  tissue  which  has  a  glistening  or  scaly  surface,  or  the  contiguous 
skin  is  covered  with  a  squamous  or  pustular  eczema,  and  is  usually  in  a 
state  of  chronic  edema  and  subacute  inflammation. 

While  syphilitic  ulcers,  originating  in  the  subcutaneous  tissues,  peri- 
osteum or  bone,  are  readily  recognized,  differentiation  from  carcinoma 
of  the  skin  is  not  easy,  especially  as  malignant  disease  not  infrequently 
develops  in  a  varicose  ulcer.  The  rapid  appearance  of  nodular,  hard 
granulations  should  arouse  suspicion ;  however,  the  edges  of  a  varicose 
ulcer  may  also  become  hard  and  nodular  as  the  result  of  the  deposit  of 
connective  tissue. 

The  extension  of  an  ulcer  of  the  leg  is  rarely  continuously  progres- 
sive. Cicatrization  and  disintegration  of  tissue  usually  alternate  and 
vary  the  clinical  picture.  When  the  ulcer  first  appears  it  is  about  the 
size  of  a  dime,  and,  as  it  extends  only  to  the  corium,  readily  undergoes 
epidermization,  by  extension  from  the  residual  papillae,  leaving  a 
delicate,  brown  pigmented  scar  which,  upon  very  slight  trauma,  breaks 
down  and  is  followed  by  the  formation  of  a  larger  ulcer.  In  this 
manner  ulcers  come  and  go  for  a  long  period  of  time  (years),  each 
resultant  scar  being  more  susceptible  to  renewed  disintegration,  until 
the  process  extends  over  the  greater  or  the  entire  circumference  of 
the  lower  leg. 

The  ulceration  is,  at  times,  associated  with  severe  pain,  especially 
when  it  is  situated  below  the  inner  malleolus,  where  it  is  subjected  to 
pressure  of  the  boot,  which  induces  the  patient  to  carry  the  foot  in 
the  supine  position.  When  the  process  is  of  long  duration  it  is  at- 
tended with  interference  of  function;  the  excessive  deposit  of  scar 
tissue  enmeshes  the  tendons,  ligaments,  and  joints,  so  that  the  foot  is 
practically  immobilized  and  is  used  like  a  stilt  (Nasse^^). 

Ulceration  not  associated  with  varicose  veins,  at  times  develops 
upon  the  leg  as  the  result  of  impairment  of  the  circulation  due  to  pro- 
longed standing  or  walking.  These  ulcers  often  provoke  thrombophle- 
bitis and  lymphangitis,  and  lead  to  development  of  phlebectasis,  which 
in  turn  causes  the  renewal  of  the  ulcerative  process. 

The  treatment  of  ulcus  cruris  varicosum  should  be  directed  toward 
the  improvement  of  the  circulation  hy  rest  and  elevation  of  the  leg, 
or,  when  this  is  impractable,  moderate  clastic  pressure  by  means  of 
flannel  or  jersey  cloth  may  be  made  (rubber  stockings  provoke  irri- 
tation of  the  skin)  ;  by  resection  of  large  dilated  veins;  and  by  liga- 


544  NECKOSIS 

ture  of  the  main  trunk  of  the  saphenous  vein  when  the  ulcer  and 
phlebectases  are  in  the  zone  of  origin  of  this  vein. 

Trauma  and  mechanical  irritation  should  be  avoided  and  cleanli- 
ness conserved  by  the  application  and  frequent  renewal  of  aseptic 
dressings,  and  lavage  of  the  surroundings  of  the  lesion. 

Reparative  granulation  may  be  favored,  bacterial  flora  lessened,  and 
the  separation  of  gangrenous  tissue  hastened  by  the  use  of  mildly  anti- 
septic moist  dressings.  Cicatrization  is  aided  by  the  removal  of  flabby 
granulations  by  means  of  the  silver  stick  or  by  curettement,  and  also 
by  excision  of  the  sclerosed  edges  of  the  ulcer. 

Persistent  ulcers  are  best  excised  "in  toto'*  and  the  residual  sur- 
face closed  by  transplant atio7i.  For  the  purpose,  cuticular  flaps  are 
more  useful  than  epidermal  strips,  as  the  latter  do  not  sustain  the 
wear  and  tear  coincident  to  the  subsequent  use  of  the  limb.  When 
feasible,  the  repair  should  be  made  by  the  pedunculated  flap  method. 

When  ambulatory  treatment  is  necessary,  TJnna's  zinc  gelatin  dress- 
ing, which  makes  equable  pressure,  absorbs  the  secretions,  and  pro- 
tects the  ulcer  from  irritation,  may  be  advantageously  used.  The  part 
is  bathed,  disinfected,  and  eczematous  patches  covered  with  Lazar's 
zinc  pasta.  The  ulcer  is  covered  with  a  layer  of  iodoform  gauze  or, 
if  granulating,  salve  may  be  used.  This  is  followed  by  encasing  the 
foot  and  lower  leg  with  zmc  gelatin  (zinc  oxid,  gelatin  aa.  20 ;  glycerin 
pur.,  aq.  dest.  aa.  80)  smoothly  covered  with  a  wet  gauze  bandage  and 
this  again  covered  with  a  layer  of  the  mixture.  The  dressing  becomes 
''set"  in  twenty-four  hours,  and  is  changed  when  the  ooze  of  the 
secretions  reaches  the  surface. 

In  severe  cases,  especially  in  old  persons,  amputation  may  be  neces- 
sary. When  prolonged  putrefactive  infection  provokes  cachexia,  and 
amyloid  degeneration  of  organs  is  feared,  in  cases  of  general  infection 
or  when  malignant  disease  develops  at  the  site  of  the  ulcer,  amputation 
cannot  be  avoided. 


BIBLIOGRAPHY 

1.  ZoGE  V.  Manteuffel.     Mittheil.  a.  d.  Grenzgeb.  Bd.  10,  1902,  with  lit. 

2.  BuNGE.     Chir.  kong.  Verb.,  1900,  ii. 

3.  RuDNiTZKi.     Quoted  by  v.  Mantevifel  No.  1. 

4.  WULFP.     Deutsoh.  Zeitsebr.  f.  Cbir.  Bd.  58,  1901. 

5.  HiGiER.     Zentrbl.  f.  Cbir.,  1901. 

6.  NossKE.     Chir.  kong.  Verb,  i,  1910. 

7.  MoszKOWioz.     Mittheil.  a.  d.  Grenzireb.  Bd.  17,  1907. 

8.  Bergemann.     Beitr.  z.  klin.  Cbir.  Bd.  G3,  1909. 


NECKOSIS  DUE  TO  DISEASES  OF  BLOOD  VESSELS    545 

9.  WiETiNG.     Deutseh.  med.  Woch.,  1908.     Deutsch.  Zeitsehr.  f.  Chir.  Bd 
IIU,  1911,  aud  Bd.  119,  1912. 

10.  WiETiNG.     Zentrbl.  f.  Chir.,  1911. 

11.  Glasstein.     Berlin,  klin.  Woch.,  1911,  No.  41. 

12.  CoxEN.     Munch,  med.  AVoch.,  1912. 

13.  Grossmaxx.     Berlin,  1900,  Hirschwahl. 

14.  HiLDCBRAXDT.     Deutsch.  Zeitschr.  f.  Chir^  1904,  Bd.  72. 

15.  Klemperer.     Therap.  d.  Gegenwart.,  1907. 

16.  Jacobsex.     Biochem.  Zeitschr.  Bd.  51,  1913. 

17.  Kausch.     Chir.  kons:.  Verh.  ii,  1904. 

18.  Elsexberg.     Arch.  f.  Derm,  and  Syph.  Bd.  24,  1892. 

19.  Nasse.     Deutsch.  Chir.,  1897. 


CHAPTER  VII 

NECEOSIS   OF   NEUKOPATHIC    OEIGIN 

Pathological  and  traumatic  lesions  of  the  central  nervous  system 
and  conducting  nerve  elements  are  followed  by  ulceratioti  of  the  skin 
and  mucous  membranes,  and  by  gangrene  and  mummification  of  the 
terminal  portions  of  the  extremities.  Exclusion  from  the  trophic  in- 
fluences of  the  nerve  centers  pla3's  an  important  role  in  the  produc- 
tion of  these  conditions;  however,  the  causative  effects  of  trauma 
{protracted  and  transient),  pressure,  and  inflammation  cannot  be 
excluded.  Tissues  deprived  of  nerve  supply  are  particularly  sus- 
ceptible to  necrosis  for  the  following  reasons :  ( 1 )  Reduced  resistance 
to  infection;  (2)  impairment  of  the  circulation  as  the  result  of  vaso- 
motor disturbances;  (3)  anesthesia  of  the  part  which  causes  injuries 
to  be  neglected. 

Inflammation  and  paralysis  of  the  trifacial  nerves  (from  injury, 
tumors,  aneurisms,  resection  of  the  ganglion  of  Gasser  for  the  relief 
of  neuralgia)  are  often  followed  by,  so-called,  ulcerative  I'eratitis  neu- 
roparalytica.  The  absence  of  sensation  in  the  cornea  causes  it  to  be 
subjected  to  harmful  extrinsic  influences  (lodgment  of  dust  and  for- 
eign bodies)  which  injure  the  epithelium;  this  fails  to  attract  the 
attention  of  the  patient  and,  together  with  the  lessened  resistance  of 
the  part,  favors  the  development  of  infection.  The  origin  of  ulcers 
of  the  mucous  membrane  of  the  tongue  and  mouth  may  also  be  attri- 
buted to  the  unci'^rlying  anesthesia  and  consequent  injury  from  the 
teeth  during  mastication. 

At  times,  ulceration  and  necrosis  develop  in  the  trunk  and  extremi- 
ties in  conjunction  with  disease  of  the  peripheral  and  central  nervous 
system,  though  here,  too,  the  cooperation  of  trauma  is  necessary  before 
extensive  destruction  of  tissue  supervenes. 

This,  not  infrequently,  occurs  in  cases  of  hemiplegia  or  paraplegia 
from  various  causes  (cerebral  and  spinal  lesions)  and  may  take  on  the 
form  of,  so-called,  acute  decuhitus  which  follows  pressure  upon  the 
paralyzed  part,  especially  in  the  region  over  the  sacrum,  on  the  back, 

546 


NECROSIS  OF  NEUROPATHIC  ORIGIN 


547 


Fig.  186. —  DEcrBirus  in  a  Paralytic  Club 
Foot  Associated  -with  a  Spina  Bifida  Oc- 
culta "WITH  Htpektrichiasis. 


and  on  the  heels  where  the 
loss    of    sensation    often 
leads  to  extensive  destruc- 
tion of  tissue  before  it  is 
discovered.      Tales    dor- 
salis  and  paralysis  of  ilie 
legs,  especially  in  spina 
bifida,  are  attended  with 
the  formation  of  obstin- 
ately    persistent,      deep, 
painless  ulcers  which  ap- 
pear  at   the  side   of   the 
foot,  where  they  usually 
originate   in   cracks    and 
fissures,  or  at  the  site  of 
injuries      of      the      skin 
{malum perforans) .  Sim- 
ilar ulcers  develop  in  con- 
junction    with     neuritis, 
but  these  are  very  pain- 
ful,      lu     syringomyelia 
(]\Iorvan   type),    and   in 
the  nerve  form  of  lepra 
the  process  appears  in  the 
form    of    mummification, 
as  a  rule,  at  the  tips  of 
the  fingers  and  toes,  and 
is  followed  by  separation 
of  the  necrosed  parts  and 
healing.     Injuries  of  the 
nerve  trunks  of  the   ex- 
tremities   are    also     fol- 
lowed by  the  formation  of 
small  neuropathic  ulcers, 
preceded    by   small    blis- 
ters,   appearing    on    the 
palms  of  the  hands  and 
soles  of  the  feet. 

The  use  of  special  ter- 


548  NECROSIS 

minolo(jij  for  symmetrical  neuropathic  necrosis;  ulceration;  Raynaud's 
disease;  and  Malum  perf oralis  pedis  is  still  in  vogue;  however,  it  is 
probable  that  these  do  not  differ  in  etiology-  nor  in  clinical  manifesta- 
tions from  other  processes  incidental  to  lesions  of  the  nerve  centers 
and  nerves. 

The  form  of  necrosis  designated  as  Raynaud's  disease  occurs  in 
3'oung  persons  and  in  children;  it  involves  the  fingers,  the  toes,  the 
ears,  the  cheeks,  and  the  nose;  it  is  usually  symmetrical,  appears  in 
the  form  of  mummification,  and  is  associated  with  nerve  and  vasomotor 
disturbances  (similar  to  ergotism).  Necrosis  is  preceded  by  severe 
pain,  tingling,  numbness,  pallor  and  coldness — the  last  two  indicating 
local  ischemia  (local  syncope).  These  manifestations  may  disappear, 
or  they  may  merge  into  the  next  stage  of  the  disease  which  is  heralded 
by  bluish  discoloration  of  the  skin  (local  c^'anosis,  asphyxia),  and  is 
soon  succeeded  by  pallor  and  the  formation  of  crusts;  finally,  com- 
plete necrosis  of  the  distal  phalanges  occurs.  The  course  of  the  dis- 
ease, with  its  varying  disturbances,  may  extend  over  j'cars,  and  may 
be  associated  with  scleroderma.  The  Rontgenogram  shows  atrophy-  of 
the  terminal  phalanges. 

The  cause  of  the  vascular  spasm  attendant  upon  the  onset  of  Ray- 
naud's disease  is  not  known.  Inflammatory  changes  in  the  walls  of 
the  blood  vessels  are  often,  but  not  constantly,  present.  Cassirer^  sug- 
gests that  the  vasomotor  centers  and  conductors  are  in  a  state  of  in- 
creased excitability,  the  result  of  a  congenital  tendency ;  repeated  irri- 
tation (by  cold,  infectious  diseases,  poisoning  with  chloral,  phosphorus, 
etc.)  ;  or  profound  emotional  impressions,  such  as  fright,  overwhelming 
misfortunes,  etc.  A  lesion  of  the  central  nervous  sj'stem  is  not  usually 
discoverable.  The  manifestations  attendant  upon,  co-called,  Ray- 
naud's disease  occur  in  cases  of  tabes  dorsalis,  syringomyelia,  epilepsy, 
hysteria,  Basedow's  disease,  and  tumors  of  the  spinal  cord. 

Differentiation  from  syringomyelia  and  lepra  is  attended  with  con- 
siderable dii^culty,  especially  when  pain  is  absent  and  when  the  signs 
of  neuropathic  necrosis  are  indefinite.  Syphilitic  and  angiosclerotic 
necrosis  are  also  likely  to  present  difficulties  in  differential  diagnosis. 

Angiospasm  is  at  times  provoked  by  the  ingestion  of  ergot,  and 
results  in  necrosis  of  the  extremities.  The  disease  {ergotism) ,  which 
is  now  very  rare  (except  in  southern  Russia),  was  widely  disseminated 
in  the  middle  ages  (0.  Weber^).  It  results  from  the  ingestion  of 
diseased  rye  in  bread,  which  produces  ergot  poisoning.  Severe  cases 
develop  sensor}^  disturbances   (tingling,  pain,  or  anesthesia),  vomit- 


NECROSIS  OF  NEUROPATHIC  ORIGIN  549 

ing-,  diarrhea,  and  convulsions,  and  die  in  a  few  days.  Milder  cases 
are  attended  with  contraction  of  blood  vessels,  an  ischemia  of  insular 
sections  of  the  body,  especially  the  extremities.  The  affected  part 
becomes  cold,  pale,  and  anesthetic ;  after  a  time,  severe  pain  develops, 
and  it  becomes  blue  in  color  and  mummification  or  gangrene  is  the 
result.  Billroth^  reports  a  case  of  ergot  necrosis  in  connection  with 
the  administration  of  large  doses  of  the  drug. 

Malum  perforans  pedis  is  a  term  applied  to  a  sloidy  developing, 
obstinately  persistent,  painless  ulcer  which  appears  upon  the  foot 
(usually  on  the  sole  at  the  head  of  the  fir.-t  and  fifth  metatarsal  bones, 
and  at  the  heel),  has  a  tendency  to  relapse  and  is  attended  with 
anesthesia  and  paresthesia.  It  occurs  in  connection  with  trophic  dis- 
turbances of  the  entire  foot,  including  the  toe  nails. 

The  destruction  of  tissue  appears  in  connection  with  a  pyogenic  in- 
fection secondary  to  a  wound  or  to  an  abscess  in  a  bursa.  It  takes  on  the 
form  of  a  deep  funnel  shaped  phagedenous  ulcer  which  has  sharply  de- 
fined undermined  edges.  The  ulcer  may  heal,  but  soon  breaks  down,  a 
process  which  may  be  several  times  repeated  until  finally  destruction 
of  the  bones  and  joints  occurs,  and  provides  a  favorable  port  for  the 
entrance  of  putrefactive  infection.  Levy*  regards  the  bone  and  joint 
involvements  as  primary.  Hofmann^  suggests  that,  as  these  may  be 
absent  or  may  appear  late  in  the  disease,  this  view  is  erroneous. 

The  process  appears  in  connection  with  diseases  and  injuries  of 
the  central  nervous  system.  Tabes  dorsalis,  syringomyelia,  spina 
bifida,  diseases  of  the  vertebrae  with  changes  in  the  spinal  cord, 
general  paralysis,  injuries,  inflammations,  and  tumors  of  the  nerve 
trunks  are  causative  factors.  Diseases  of  blood  vessels  which  may,  at 
times,  coexist  with  lesions  of  the  nervous  system,  do  not  stand  in  a 
causative  relationship  to  this  form  of  necrosis. 

Diabetes  is  at  times  attended  with  an  ulcer  of  this  sort,  the  result 
of  a  complicating  neuritis,  but  it  is  readily  differentiated  from  classic 
diabetic  gangrene. 

Similar  ulcers  also  occur  in  neglected  wounds  or  arise  in  connec- 
tion with  angiosclerosis  or  syphilis;  however,  the  character  of  pain 
and  the  absence  of  nervous  di.sturbances  should  make  the  distinction. 

The  small  multiple  foci  of  cutaneous  necrosis,  also  called  neuropara- 
lytic ulcers  of  the  skin,  herpes  zoster  gangrenosus,  and  gangrenous 
urticaria,  extend  over  the  entire  body  and  are  associated  with  various 
diseases  of  the  nervous  system.    A  similar  condition  of  the  skin  is.  at 


550  NECROSIS 

times,  produced  by  hysterical  patients  who  use  caustic  soda  for  the 
purpose  (Cassirer^). 

The  treatmeyit  of  neuropathic  necrosis  should  be  directed  toward 
the  removal  of  the  cause,  which  is,  of  course,  a  difficult  problem.  In 
other  regards  the  rules  governing  the  care  of  angiosclerotic  necrosis 
should  be  followed.  When  ulceration  is  established,  the  edges  of  the 
ulcer  may  be  excised  and  the  lesion  treated  in  accord  with  general  sur- 
gical principles.  Dead  bone  must  be  removed  and  purulent  joints 
drained  or  excised.  Complete  excision  of  ulcers  is  often  followed  by 
healing.  Chipault''  claims  that  when  this  is  supplemented  by  stretch- 
ing of  the  main  nerves  supplying  the  necrotic  area,  recurrence  may  be 
prevented. 

BIBLIOGRAPHY 

1.  Cassirer.     Zentrbl.  f.  Grenzgeb.,  1900,  with  lit. 

2.  0.  Weber,     v.  Pitha  and  Billroth,  Handb.  d.  Chir.,  1865,  i, 

3.  Billroth.     Same  as  Weber  No.  2. 

4.  Levy.     Chir.  kong.  Verb.,  1910,  i. 

5.  HoFMANii.     Beitr.  z.  klin.  Chir.  Bd.  73,  1911„ 

6.  Chipault.     Gaz.  des  hosp..  No.  41,  1901. 


PART  IV 

INJUEIES  OF  THE  SOFT  PAKTS,  BOXES  AND  JOINTS  AND 
THEIR  TREATMENT 


CHAPTER  I 

IXJUEIES 

An  injury  (laesio)  is  a  sudden  forcible  alteration  of  tissue  which 
results  in  a  solution  of  continuity,  a  separation  of  its  connection  with 
other  tissues  or  merely  a  disturbance  of  enervation  {concussion) .  The 
agents  concerned  in  producing  injury  are  numerous,  but  may  be 
grouped  under  the  general  heads  of  mechanical,  chemical  and  thermal. 

MECHANICAL  INJURIES 

General  Classification  of  Mechanical  Injuries. — Injuries  are  divided 
into  contusions,  lacerations  and  concussions,  together  with  the 
special  varieties  occurring  in  certain  kinds  of  tissues,  such  as  frac- 
tures of  bones,  dislocations  of  joints,  and  suMuxations  of  tendons  and 
nerves. 

Wounds. — Wounds  are  caused  by  sharp  or  blunt  objects,  by  com- 
pression or  b}'  crusliing  or  tearing  forces  applied  to  the  skin,  mucous 
membranes,  and  the  surfaces  of  organs.  Simple  wounds  have  already 
been  considered  (Part  I.,  chap.  ii.). 

A  contusion  is  an  injury'  in  which  the  tissues  have  been  subjected  to 
a  degree  of  pressure  incompatible  with  their  resistance.  Injuries  of 
this  nature  are  caused  by  the  application  of  blunt  force,  and  are  the 
effect  of  forcible  contact  on  the  part  of  the  body  with  a  hard  sub- 
stance. The  soft  parts  are  either  forced  against  the  bone  or  are 
crushed  between  two  hard  surfaces.  The  latter  may  involve  con- 
siderable areas  of  the  body,  as  for  instance,  when  a  person  is  caught 
between  the  side  of  a  craft  and  a  pier  or  between  two  railroad  cars. 
Contusions  occur  onl.v  where  the  soft  parts  are  crushed  against  the 
protruding  corners  of  bones.  As  the  skin  is  more  resistant  than  fat 
or  muscle,  its  integrity  may  be  maintained  when  the  underlying  parts 
are  mashed  into  a  blood}'  pulp  quite  separated  from  all  attachments. 

A  contusion  is  not  alone  the  result  of  compression,  but  is  also  due 
to  tearing,  the  outcome  of  a  certain  degree  of  lateral  motion  on  part 

553 


554     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

of  the  provocative  force.  In  contusiotis  of  moderate  degree,  the  tear- 
ing of  soft  parts  is  limited  to  the  loose  connective  tissue  and  the 
smaller  blood  and  lymph  vessels;  in  the  severe  form  the  tissues  may 
be  separated  entirely  from  one  another,  yet  the  individual  cellular 
elements  be  preserved. 

The  symptoms  of  contusion  are  pain,  loss  of  function,  and  sivelling 
from  effusion  of  blood.  To  these  may  be  added  the  appearance  of 
ecchymosis  which  is  usually  proportionate  to  the  extent  of  the  injury. 

Lacerations  are  due  to  the  stretching  of  tissue,  the  result  of  tearing 
force.  This  force  is  applied  obliquely  from  without,  or  may  originate 
from  within  the  body.  When  the  tissues  are  stretched  beyond  the 
capacity  of  their  elasticity,  they  tear  or  lacerate,  the  separation  tak- 
ing place  in  the  intercellular  tissues,  rarely  in  the  parenchyma.  "When 
the  gross  anatomical  structure  of  a  part  is  preserved,  the  term  stretch- 
ing is  used.  When  the  skin  is  torn  it  is  called  a  lacerated  wound; 
when  the  force  acts  from  within  outward,  the  term  bursting  wound  is 
employed ;  and  when  the  tissues  are  separated,  it  is  termed  a  rupture. 

Pain,  loss  or  impairment  of  function  and  swelling  from  extravasa- 
tion of  blood  are  the  symptoms  of  lacerated  and  ruptured  wounds. 

Concussion  is  the  effect  of  blunt  force  (thrust,  blow  or  fall),  not 
sufficiently  powerful  to  produce  discernible  alteration  of  tissue  in  the 
form  of  a  separation  of  its  normal  relationship.  The  extent  of  the 
concussion  may  be  limited  to  certain  areas  of  the  body  or  may  be  con- 
veyed to  distant  parts.  In  the  former  instance,  the  provocative  force 
is  very  likely  to  be  attended  with  a  certain  degree  of  solution  of  con- 
tinuity of  tissue.  The  manifestations  of  this  form  of  injury  consist 
of  pain  or  loss  of  sensation  and  loss  of  function,  all  of  which  are  de- 
pendent upon  injury  to  the  nerve  substance.  They  find  expression  in 
the  tissues  contiguous  to  contused  or  lacerated  wounds  and  are  grouped 
under  the  general  head  of  local  shock  or  wound  stupor.  As  a  rule,  the 
symptoms  soon  disappear. 

Very  often,  especially  in  cases  of  severe  injury  attended  with  gen- 
eral shock,  tissue  concussion  or  local  shock  escapes  notice.  On  the 
other  hand,  few  persons  pass  through  life  without  experiencing  the 
phenomenon  described.  It  occurs  in  connection  with  striking  the 
ulnar  nerve  on  a  hard  surface,  and  often  follows  the  act  of  jumping 
on  a  hard  surface  with  the  limbs  held  rigid.  A  dull  heavy  pain  passes 
through  the  legs,  which  are  momentarily  numb  and  feel  paralyzed ;  in 
a  few  moments  the  numbness  is  succeeded  by  a  sensation  of  tingling 
and  function  is  soon  fully  restored. 


INJURIES  555 

Dangerous  and  even  fatal  forms  of  concussion  occur  in  connection 
with  the  brain,  spinal  cord,  thorax,  and  abdomen.  Injuries  of  this 
sort  are  usually  complicated  by  other  conditions,  such  as  severe  con- 
tusions, lacerations  or  rupture  of  more  or  less  important  parts,  organs, 
and  tissues  of  the  bod}^,  and,  therefore,  do  not  present  a  clearly  de- 
fined clmical  entity.  Pure  concussion  of  the  brain  follows  injury  to 
the  cerebral  centers,  the  nature  of  which  is  not  clearly  understood. 
Its  occurrence  is  manifested  by  transient  loss  of  consciousness,  con- 
fusion of  ideas,  usually  vomiting  and  a  more  or  less  rapid  return  to 
the  normal.  The  occurrence  of  yure  concussion  of  the  spine  has  been 
questioned.  Most  observers  consider  the  clinical  picture  following 
trauma  in  this  connection  to  be  due  to  more  or  less  contusion  of  the 
spinal  cord  as  the  result  of  changes  in  the  relationship  of  the  vertebral 
bodies  to  one  another.  It  is  easy  to  see  that  a  sharp  line  cannot  be 
drawn  in  this  class  of  cases.  Observations  in  connection  with  transient 
motor  and  sensory  symptoms  which  follow  the  fall  of  an  aviator  and 
entirely  disappear  after  a  brief  period  of  rest  would  seem  to  justify 
the  assumption  that  tissue  shock  of  the  spinal  cord  does  occur  and, 
if  there  be  no  persistent  subsequent  disturbances,  it  is  proper  to  assume 
that  no  destruction  of  cellular  elements  has  occurred.  Concussion  of 
the  thorax  and  abdomen  are  evinced  by  the  clinical  picture  of  shock, 
and  are  expressed  by  disturbances  of  the  vasomotor  apparatus,  of  the 
inhibitory  function  of  the  vagus,  and  of  the  sj^mpathetic  and  splanch- 
nic distributions. 

The  coexistence  of  contusion,  laceration  and  concussion  of  tissue  is 
frequcnth^  observed,  especially  in  cases  of  injury  by  grenade  splinters 
or  by  high  velocity  projectiles.  A  finel}''  drawn  distinction  under  these 
conditions  is  impossible.  From  the  standpoint  of  prognosis,  it  is  well 
to  bear  in  mind  that  the  local  symptoms  following  injury  may  be,  in 
a  measure,  due  to  concussion,  and  that  this  aspect  of  the  situation  will 
be  cleared  up  in  a  few  hours. 


CHAPTER  II 

THE   MECHANICAL   IXJUEIES   OF   THE   DIFFEKENT   TISSUES 

Injuries  of  the  Skin,  Subcutaneous  Tissues  and  Mucous  Membranes. — 
Beyond  the  simple  wounds  already  described  (p.  27),  injuries  of 
the  skin  are  classified  as  excoriations  and  contusions  and  are  attended 
with  more  or  less  extravasation  of  hlood.  Excoriations,  or  abrasions, 
are  the  result  of  blunt  force.  They  frequently  occur  on  the  chin  or 
knee  and  follow  gliding  contact  with  hard  surfaces.  The  epidermis  is 
usually  scraped  away,  exposing  the  bleeding  or  slightly  ''weeping" 
corium,  which  is  extremely  sensitive.  As  a  rule,  particles  of  dirt, 
sand,  splinters  of  wood  or  other  foreign  substances  are  embedded  in 
wounds  of  this  sort.  The  rapidly  forming  serosanguineous  exudate 
soon  dries  and  forms  a  crust  beneath  which  healing  takes  place  unless 
infection  intervenes. 

The  latter  possibility  renders  it  imperative  that  the  vicinity  of  the 

W'OUND    BE    CLEANSED    AND    ALL    FOREIGN    PARTICLES     CAREFULLY    AND 

THOROUGHLY  REMOVED  from  the  raw  surface.  This  is  followed  by 
the  application  of  a  dry  aseptic,  protective  dressing  which  ordinarily 
does  not  need  to  be  removed  until  healing  is  accomplished. 

Contusions  of  the  skin  follow  a  variable  course.  When  the  skin 
lies  directly  over  the  bone  (like  the  shin),  the  injury  is  likely  to  be 
followed  by  more  or  less  necrosis.  On  the  other  hand,  the  contusion 
may  be  followed  by  subcutaneous  bleeding  which  is  manifested  in  the 
form  of  discoloration  due  to  the  extravasation  of  blood.  In  some  in- 
stances the  contusing  force  is  followed  by  the  development  of  an 
hemorrhagic  hleb.  "When  the  bleb  is  forcibly  removed,  infection  is 
likely  to  follow,  therefore,  they  should  not  be  disturbed  but  be  pro- 
tected with  a  dry  aseptic  dressing  which  is  promptly  followed  by 
healing  without  scarring.  When  a  bleb  is  accidentally  removed,  the 
resultant  raw  surface  is  treated  in  the  manner  described  in  connec- 
tion with  excoriations. 

Contusion,  laceration,  stretcliing,  and  crushing  of  the  subcutaneo's 
tissue  often  follows  the  application  of  blunt  force,  when  the  more 

556 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     557 

elastic  superimposed  skin  escapes  injury.  Trauma  of  this  nature  is 
usually  followed  by  hemorrhagic  infiltration  of  the  subcutaneous  tissue 
which  may  distend  its  meshes.  Simple  infiltration  of  blood  indicates 
rupture  of  capillaries  or  small  blood  vessels;  the  formation  of  a 
cavity,  filled  with  blood,  is  the  result  of  injury  to  a  large  artery  or 
vein.  The  appearance  of  small  areas  of  bloody  infiltrate  is  called 
ecchymosis  or  petcchiae;  the  large  blond  collections  are  called  hema- 
tomata.  Both  ecchymosis  and  hematomata  may  be  circumscrihed  or 
widely  disseminated.  In  hemophiliacs,  comparatively  slight  trauma 
may  be  followed  by  hemorrhagic  infiltration  or  by  the  formation  of 
hematomata  involving  considerable  areas  of  the  body. 

Ordinarily,  subcutaneous  bleeding  is  rapidly  arrested;  the  torn 
blood  vessels  contract  and  the  pressure  of  the  surrounding  tissues 
favors  coagulation.  When  large  hematomata  are  formed,  coagulation 
is  incomplete,  being  limited  to  the  walls  of  the  adventitious  cavity, 
in  addition  to  this,  the  lymph  extravasated  at  the  same  time  as  the 
blood  coagulates  very  slowly  and  interferes  with  the  formation  of 
fibrin. 

Absorption  of  extravasated  blood  is  accomplished  by  the  lymph 
channels.  It  occurs  more  rapidlj'  in  cases  of  simple  infiltration  than 
when  hematomata  are  formed,  since  the  latter  are  attacked  only  from 
their  peripheral  walls.  The  serum  is  absorbed  by  the  lymphatics, 
though  a  certain  number  of  blood  cells  are  taken  up  in  this  way. 
Fibri ji  is  taken  up  as  the  result  of  the  digestive  action  of  the  cellular 
elements  which  are  proliferated  from  the  surrounding  tissues. 

The  hemoglobin  left  in  sitio  by  the  disintegrated  red  blood  corpus- 
cles, penetrates  and  discolors  the  surrounding  tissues  to  a  consider- 
able extent.  It  is  gradually  absorbed  by  the  fluids  of  the  body,  and  is 
excreted  by  the  liver  in  the  form  of  bile  coloring  matter  and  is  in  part 
thrown  off  by  the  kidneys.  A  small  residue  usually  remains  at  the 
seat  of  the  injury  and  is  very  gradually  transformed  into  blood  pig- 
ment, i.  e.,  hrniosiderin  and  hematoidin  crystals,  both  of  which  are 
formed  within  and  between  the  cells. 

The  fihrin  and  the  severely  injured  tissues  are  gradually  digested 
and  replaced  by  proliferated  granulation  tissue.  As  a  rule,  the  newly 
formed  connective  tissue  {scar)  is  harder  in  consistency  than  normal 
tissue. 

The  manifestations  of  subcutaneous  blood  effusions  are  pain;  dis- 
coloration of  the  skin — which  is  tinted  in  accord  with  the  degree  of 
injury  and  the  looseness  of  the  subcutaneous  meshes;  swelling,  either 


558     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

definitely  or  indistinctly  outlined;  fluctuation  or  crepitation  (snow- 
ball crepitation)  ;  the  latter,  depending  upon  the  character  of  effusion, 
varying  from  distinct  crepitation  to  fluctuation.  The  formation  of  a 
pulsating  hematoma  follows  the  rupture  of  an  artery  of  considerable 
size.  Circumscribed  hcmatomata  may  be  distinguished  by  the  de- 
velopment of  a  crater-like  depression,  surrounded  by  a  hard  edge  of 
induration  which  consists  of  fibrin.  Aseptic  fever  (page  189)  at  times 
attends  extensive  extravasation  of  blood. 

The  disappearance  of  pain  and  swelling  occurs  in  from  a  few  days 
to  several  weeks,  depending  upon  the  extent  of  the  extravasation. 

Discoloration  spreads  over  wide  areas  and  varies  in  tint,  being  at 
first  dark  blue,  later  green,  and  ultimately  yellow;  the  latter  persisting 
for  the  longest  period  of  time. 

The  treatment  of  suh cutaneous  extravasation  of  blood,  not  attended 
with  inflammation,  consists  of  immobilization  of  the  part  and  the 
employment  of  slight  pressure,  which  lessens  the  pain,  prevents  the 
increase  of  bleeding  and  promotes  absorption.  The  use  of  the  ice 
bag  or  cold  compresses  is  of  signal  service  in  this  connection.  At  the 
end  of  a  week,  massage  may  be  employed.  Extensive  hematomata  may 
be  emptied  by  puncture  or  by  aspiration.  When  suppuration  occurs, 
immediate  incision  should  be  resorted  to. 

At  times,  large  hematomata  do  not  undergo  appreciable  absorption, 
especially  when  located  in  portions  of  the  body  where  the  circulation 
is  terminal  (brain,  retroperitoneal  space,  certain  muscles,  etc.).  Under 
these  conditions  the  area  of  extra vasated  blood  is  surrounded  by  a  wall 
of  newly  formed  connective  tissue,  and  a,  so-called,  blood  cyst  is  the 
result.  These  cysts  are  filled  with  a  chocolate  colored  fluid  or  semi- 
fluid mass  consisting  of  fluid  lymph  and  blood  detritus,  and  contain 
blood  pigment,  crystals  of  hematoidin,  and  numerous  cholesterin 
plates,  which  latter  are  the  residue  of  disintegrated  particles  of  fat. 
As  time  goes  on  the  wall  of  the  cyst  thickens  and  may  be  the  seat  of 
calcareous  or  bony  deposits  {traumatic  blood  or  lymph  cysts).  Aspira- 
tion and  the  injection  of  irritants,  such  as  iodin,  alcohol,  carbolic  acid, 
and  iodoform  glycerin  may  result  in  obliteration  of  the  adventitious 
cavity ;  failing  in  this,  excision  of  the  newly  formed  wall  may  be  neces- 
sary. "When  the  cavity  is  large,  excision  of  a  part  of  its  wall  and 
suture  of  the  remaining  portion  to  the  skin,  followed  by  the  so-called 
open  wound  treatment,  will  accomplish  the  desired  result. 

Postoperative  hematomata  occur  when  complete  hemostasis  has  not 
preceded  closure  of  the  operative  wound.     This  contingency  is  fol- 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     559 

lowed  by  more  or  less  leakage  of  fluid  blood  which  escapes  between  the 
stitches ;  in  most  instances,  however,  a  considerable  quantity  of  coagu- 
lum  is  retained,  causing  pain  and  swelling.  In  these  instances,  the 
wound  should  be  freely  opened  and  the  clot  gently  expressed  by  means 
of  pressure,  using  gauze  pads  for  the  purpose ;  the  bleeding  point  is 
deligated  in  the  usual  manner.  Following  this  the  wound  may  be 
lightly  packed  with  iodoform  gauze  which  is  removed  on  the  third  day 
and  the  wound  resutured. 

Neglect  of  the  thorough  arrest  of  bleeding  in  connection  with  opera- 
tive wounds  is  very  likely  to  be  followed  bj^  extravasation  of  blood 
and  the  development  of  infection.    For  these  reasons,  vessels  drtded 

DURING  AN   OPERATION  SHOULD  BE   IMMEDIATELY   CLAMPED.      "When  this 

is  omitted  smaller  vessels  are  apt  to  contract  and  become  filled  with 
coagulated  blood.  Later,  when  the  patient's  blood  pressure  returns  to 
the  normal,  the  clots  are  forced  out  of  the  veins  and  the  formation  of 
a  hematoma  not  infrequently  follows.  This  is  also  liable  to  occur  when 
infiltration  anesthesia,  or  the  local  application  of  suprarenal  extract, 
are  employed  in  so-called  minor  operations. 

Separation  of  the  skin  from  the  subcutaneous  tissue  is  followed  by 
serious  results,  and  usually  occurs  when  the  skin  is  torn  from  its 
attachments  by  obliquely  applied  blunt  force,  such  as  the  wheel  of  a 
vehicle.  The  space  beneath  the  loosened  skin  is  filled  with  extra- 
vasated  blood  and  lymph,  and,  in  many  instances,  the  subcutaneous 
tissues  are  crushed  and  torn.  The  injury  is  manifested  by  the  SAonp- 
toms  of  hematoma  or  the  extravasation  of  lymph. 

The  characteristics  of  the  extravasation  of  lymph,  following  ex- 
tensive separation  of  the  skin,  differ  from  those  evinced  by  the  forma- 
tion of  a  hematoma  and  were  first  described  by  Morrell-Lavalee^  under 
the  name  of  decoUcmcnt  de  la  peau,  but  were  more  fully  discussed 
by  Kohler,"  Extravasation  of  hTnph  develops  gradually,  reaching 
its  maximum  in  several  days;  while  the  swelling  of  a  hematoma  ap- 
pears in  a  few  hours  after  the  receipt  of  the  injure*.  The  leakage  of 
lymph  is  serous  in  character,  though,  at  times,  the  fluid  is  stained  with 
blood.  The  lymph  tumor  does  not  possess  the  tenseness  peculiar  to 
hematoma,  as  the  extravasation  in  the  former  instance  is  only  equiva- 
lent to  the  general  lymph  pressure,  which  is  low.  The  form  of  the 
swelling  varies  with  the  position  of  the  part  and  fluctuation  is  readily 
elicited.  Subcutaneous  hnnphorrhagia  occurs  most  often  in  the  thigh, 
though  enormous  extravasations  have  occurred  upon  the  trunk  (Fie- 
biger^).     When  the  skin  alone  is  separated,  the  term  superficial  de- 


560     INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 

collement  is  used,  separation  of  the  muscles  and  the  periosteum  from 
the  bone  is  called  deep  clecollement. 

The  treatment  of  suhcutaneous  separation  of  the  skin  consists  of 
cleansing  of  the  injured  area,  and  immohilization  of  the  part  under 
light,  equable  pressure.  The  extent  of  the  separation  decides  the 
question  of  necrosis;  when  this  occurs,  the  dead  skin  is  removed  and 
the  raw  surface  covered  with  some  sort  of  graft  (p.  144).  Large 
effusions  of  lymph  should  be  removed  by  aspiration,  which  may  be 
followed  by  the  injection  of  alcohol  or  5  per  cent  iodin  solution.  In- 
cision is  indicated  in  impending  necrosis  or  when  infection  (which  is 
very  likelj^  to  happen)  develops. 

Complete  avulsion  of  the  skin  occurs  most  frequently  m  persons 
engaged  in  the  operation  of  rotating  machinery.  The  hair  is  caught 
in  belting  or  in  the  meshes  of  gears,  and  the  scalp  entirely  torn  off. 
Cases  of  complete  avulsion  of  the  skin  of  the  penis  and  scrotum  have 
also  been  observed.  Wounds  of  this  sort  are  treated  on  general  prin- 
ciples. As  a  rule,  the  defect  is  sufficiently  extensive  to  demand  repair 
by  transplantation  of  skin  or  by  grafting. 

Injuries  of  mucous  membranes  do  not  differ  from  those  of  the  skin, 
except  that  they  are  not  as  likely  to  be  infected.  On  the  other  hand, 
submucous  extravasation  of  blood  is  often  very  extensive.  In  the 
larynx,  the  swelling  may  cause  suffocation  and  in  the  stomach  and  gut, 
the  interference  with  nutrition  consequent  to  injuries  of  this  class 
(especially  gunshot  wounds)  leads  to  perforation  of  the  wall  of  the 
injured  viscus. 

Traumatic  emphysema  is  the  result  of  injuries  of  the  air  passages, 
in  which  air  escapes  into  the  subcutaneous  and  intermuscular  cellular 
tissue.  The  accumulation  of  air  is  due  to  the  pressure  of  expired  air 
and  may  follow  along  the  course  of  the  blood  vessels  and  gain  access  to 
important  organs. 

Mild  forms  of  the  affliction  occur  in  connection  with  open  injuries 
of  the  nasal  bones,  the  frontal  sinus,  and  the  mastoid  process.  The 
first  is  especially  marked  when  patients  attempt  to  clear  the  nasal 
pas.sages  by  forcible  expiration  of  air  through  the  nose.  Severe  forms 
occur  in  connection  with  fractured  ribs,  when  the  lung  is  perforated,  in 
eases  of  gunshot  or  stab  wounds  of  the  lung,  and  when  the  larnj^x  or 
trachea  are  perforated  as  the  result  of  tuberculous,  syphilitic  or  can- 
cerous'destruction  of  tissue. 

At  times,  emphysema  of  the  soft  parts  follows  tracheotomy  when 
air  escapes  in  the  tissues  by  the  side  of  a  tightly  fitting  tube,  or  when 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     561 

the  tube  is  obstructed  by  blood  or  by  secretions.  The  condition  has 
been  observed  after  celiotomy  executed  in  the  Trendelenburg  pos- 
ture, or  when  the  operation  has  been  followed  by  severe  coughing  or 
prolonged  vomiting;  the  air  which  gained  access  to  the  abdominal 
cavity  being  forced  into  the  cellular  tissue  of  the  abdominal  wall.  In 
some  instances  the  air  gains  access  to  the  tissues  by  means  of  the 
irrigating  tube,  though  this  is  rare.  The  firing  of  a  blank  cartridge 
at  close  range  may  be  followed  by  the  development  of  gas  which  has  its 
origin  in  the  powder  forced  into  the  soft  parts  (Hammer*). 

Suhciitaneoiis  empJiysema  is  characterized  by  the  development  at 
the  site  of  the  injury  of  a  soft,  elastic  swelling,  with  indistinct  bound- 
aries, which  crackles  on  palpation,  gives  a  tympanitic  percussion  note, 
disappears  on  pressure,  and  is  not  painful.  The  swelling  may  extend 
very  rapidly  (especially  when  the  patient  is  restless)  and  may  spread 
over  the  entire  body.  At  times  large  portions  of  the  body  take  on  the 
appearance  of  a  tensely  distended  balloon. 

In  mild  cases  the  air  begins  to  be  absorbed  in  two  or  three  days, 
and  the  swelling  rapidly  disappears. 

In  severe  cases  the  danger  lies  in  invasion  of  the  thoracic  cavity. 
From  the  neck  the  emphysematous  infiltrate  gains  access  to  the  pleural 
sac  or  enters  the  mediastinum.  In  this  way  the  lungs  or  the  heart 
are  compressed  and  death  from  suffocation  ensues.  These  contingen- 
cies are,  however,  not  frequent.  It  is  not  uncommon  to  see  extensive 
areas  of  the  body,  including  the  face  and  neck,  tensely  distended  with 
infiltrated  air,  and  the  patient  make  a  complete  recovery. 

Traumatic  emphysema  is  readih'  differentiated  from  gas  phlegmon 
by  the  absence  of  the  evidence  of  infection  in  the  former  instance. 

The  treatment  is  directed  toward  the  removal  of  the  cause,  i.  e., 
the  opening  through  which  the  air  enters  the  tissues  should  be  closed 
or  free  access  should  be  given  the  infiltrating  air.  Sauerbruch^  ob- 
served the  air  rapidly  disappear  from  the  tissues  after  the  patient  was 
placed  in  the  negative  pressure  cabinet  and  the  liberating  incision  had 
been  made. 

The  nose  may  be  closed  by  tamponade.  Wounds  of  the  larnyx  and 
trachea  should  be  closed  by  suture  and  the  tidal  air  diverted  with  a 
tracheotomy  tube  inserted  below  the  point  of  puncture.  In  cases  of 
pneumothorax,  firm  tamponade  may  be  employed,  or  the  puncture 
wound  in  the  parietal  pleura  may  be  exposed  and  closed  hy  suture; 
when  this  fails,  a  tube  provided  with  a  valve  (v.  Bramann^)  which 
permits  only  of  the  escape  of  air  may  be  inserted  into  the  puncture. 


562     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  same  plan  may  be  followed  in  cases  of  fractured  ribs  with,  punc- 
ture of  the  lung,  though,  as  a  rule,  simple  compression  of  the  injured 
area  obviates  additional  escape  of  air  into  the  tissues.  In  many  in- 
stances, free  incision  of  the  part  gives  egress  to  the  infiltrated  air  and 
is  promptly  followed  by  disappearance  of  the  symptoms  (Koenig''), 

Injuries  of  Fascia  and  Muscle. — Subcutaneous  Injuries. — Subcu- 
taneous tearing  of  muscle  fascia  is  caused  by  sudden  violent  contrac- 
tion of  the  muscle,  or  occurs  in  connection  with  other  injuries  such  as 
fractures,  contusions,  etc. 

The  tear  in  the  fascia  may  be  palpable  in  the  form  of  a  transverse 
or  oblique  hollow  most  noticeable  when  the  muscle  is  relaxed.  In 
most  instances  the  protruding  muscle  fiber  is  also  readily  palpable. 
When  the  muscle  itself  is  intact  the  muscle  hernia  disappears  when 
the  muscle  is  in  contraction,  but  becomes  larger  when  the  reverse 
obtains  (Lexer  and  Baus^). 

Operative  repair  of  simple  rupture  of  muscle  fascia  is  rarely  neces- 
sary. When  the  repair  is  executed,  subcutaneous  suture  with  catgut 
and  temporary  immobilization  of  the  part  is  followed  by  prompt  re- 
covery. In  cases  of  extensive  muscle  hernia,  the  torn  protruding 
muscle  fiber  should  be  excised  and  repair  of  the  muscle  fiber  made  as 
stated. 

Crushing  injuries  of  fascia  usually  occur  when  the  muscle  is  injured 
in  a  similar  manner.  In  a  general  way,  it  may  be  said  that  injury  to 
fascia  is  more  likely  to  be  followed  by  sloughing  than  in  skin  or 
muscle.  This  is  ascribable  to  the  relative  lack  of  blood  supply  fur- 
nished fascial  tissue. 

Contusion  of  muscles  results  from  a  fall  or  blow  (blunt  force),  es- 
pecially when  the  muscle  is  forced  against  the  bone ;  it  is  also,  though 
infrequently,  caused  by  the  bite  of  a  large  mouthed  animal  (horsCp 
etc.).  Mild  grades  of  the  injury  are  followed  by  a  sanguineous  infil- 
trate of  the  muscle,  severe  ones  by  disintegration  of  the  muscle  fiber 
which  takes  on  the  form  of  a  muscle  hematoma. 

The  injury  is  manifested  by  incomplete  contracture  of  the  muscle, 
which  is  usually  found  in  a  state  of  fibrillary  twitching.  Additional 
symptoms  are  lessening  of  function,  pain,  arid  swelling.  Fluctuation 
may  be  detected  when  a  hematoma  of  considerable  size  is  formed. 
Discoloration  of  the  skin  is  present  only  when  the  fascia  and  the 
subcutaneous  tissues  are  injured. 

The  outcome  of  contusion  of  muscles  is  variable.  In  many  instances, 
the  symptoms  disappear  in  a  few  weeks.     The  disintegrated  muscle 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     563 

fiber  is  replaced  by  the  formation  of  a  granulation  tissue  node  of 
variable  size  {traumatic  myositis  fibrosa).  After  a  time,  muscle  fibers 
proliferate  into  deposits  of  this  sort  which  remain  unchanged  in  other 
regards  and  do  not  interfere  with  function  unless  they  are  very  ex- 
tensive in  area.  Under  the  latter  conditions,  deposit  of  connective 
tissue  may  cause  contracture  of  the  affected  muscle.  In  a  limited  num- 
ber of  cases,  the  injured  muscle  is  the  seat  of  bony  deposits  {myositis 
ossificans  traumatica)  which  may  be  due  to  a  single  trauma,  to  re- 
peated irritation,  or  may  follow  lymphogenous  or  hematogenous  sup- 
puration. Extensive  destruction  of  muscle  is  usually  followed  by 
encapsulated  hematoma  or  extravasation  of  lymph.  Residual  collec- 
tions of  this  sort  are  often  situated  in  the  upper  portion  of  the  thigh, 
and,  as  a  rule,  do  not  seriously  interfere  with  function,  though  their 
simple  presence  may  give  rise  to  considerable  annoyance. 

The  treatment  consists  of  rest  and  moderate  evenly  applied  pressure. 
At  the  end  of  a  week,  massage  may  be  employed,  which  in  most  cases 
is  followed  by  the  disappearance  of  pain,  and  the  return  of  function 
in  about  two  weeks.  Large  hematoma,  Mood  or  lymph  cj'sts  may  have 
to  be  repeatedly  aspirated.  In  obstinate  cases  complete  excision  of 
the  adventitious  sac  is  necessary.  The  tendons  of  shrunken  and  con- 
tracted muscles  may  have  to  be  divided,  or  muscle  or  tendon  transplan- 
tation may  be  required  before  function  is  restored.  Suppurating 
muscle  hematomata  are  treated  like  abscesses. 

Lacerations  of  muscle  may  be  complete  or  incomplete,  and  may  in- 
volve the  belly  of  the  muscle  alone  or  extend  into  the  tendon.  The 
lesion  may  be  produced  by  overstretching  of  passive  muscles,  such  as 
occurs  in  difficult  breech  deliveries,  in  which  the  sternomastoid  is  torn, 
and  during  reduction  of  congenital  dislocations  of  the  hip,  when  the 
abductor  muscles  give  way.  In  other  instances,  muscles  tear  as  the 
result  of  violent  contraction  of  their  fibers  when  the  muscle  is  on  the 
stretch.  Muscles  are  more  likely  to  tear  when  tense  than  when  pas- 
sive. 

.Examples  of  laceration  of  muscles  (which  usually  happens  in 
muscular  men,  especially  athletes)  may  be  cited  as  follows:  Rupture 
of  the  quadriceps  femoris  and  rectus  ahdominis  in  an  effort  to  prevent 
a  fall  backward;  of  the  quadriceps  femoris  or  the  muscles  of  the  calf 
in  jumping;  rupture  of  the  long  head  of  the  biceps  in  lifting  a  heavy 
weight ;  or  rupture  of  the  muscles  of  the  shoulder,  neck,  hack  or  ab- 
domen while  wrestling  or  during  sudden  violent  movements;  and 
rupture  of  the  adductors  in  cavalrymen. 


564     INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 

Tearing  or  rupture  of  muscles  also  occurs  as  the  result  of  direct 
violence.  This  is  often  found  to  be  the  case  in  the  muscles  of  the 
abdominal  wall.  Diseased  muscles  are  particularly  liable  to  rupture. 
Comparatively  slight  force  will  tear  the  muscles  of  patients  afflicted 
with  grave  constitutional  diseases  such  as  tj'phoid  fever,  scarlatina, 
general  infections,  etc.  The  rectus  abdominis  has  been  known  to 
rupture  upon  the  first  attempt  the  patient  made  to  arise  from  bed 
after  a  prolonged  illness.  Muscles  are  also  torn  and  lacerated  in  con- 
nection with  other  injuries,  such  as  fractures  and  dislocations. 

The  symptoms  of  rupture  of  a  muscle  are  quite  characteristic.  Its 
occurrence  is  attended  with  sudden  darting  pain  and  complete  loss  of 
function  of  the  affected  muscle.  At  times  the  patient  experiences  a 
distinct  "snap"  as  the  muscle  tears.  At  first,  the  site  of  the  rupture 
is  more  or  less  distinctly  palpable  in  the  form  of  a  hollow  space,  later 
this  is  replaced  by  the  formation  of  a  hematoma.  Contraction  of  the 
muscle  increases  the  width  of  the  cleft  and  the  two  separated  muscle 
stumps  mixj  be  felt  to  move.  Muscles  entirely  separated  from  the 
bone  ma}^  be  felt  in  the  form  of  a  hard  movable  mass.  Incomplete 
rupture  of  a  muscle  is  characterized  by  the  formation  of  an  indefi- 
nitely outlined  mass,  and  by  restricted  swelling  due  to  hemorrhagic 
infiltrate.' 

Repair  of  ruptured  muscles  takes  place  by  the  formation  of  scar 
tissue  and  is  followed  by  complete  return  of  function.  In  cases  of 
incomplete  rupture,  the  proliferated  connective  tissue  leaves  an  area 
of  thickening  {muscle  callus)  which  ultimately  disappears.  In  a  cer- 
tain number  of  cases,  cicatricial  contraction  may  cause  deformity 
(such  as  wry  neck). 

The  treatment  of  incomplete  rupture  of  a  muscle  is  the  same  as  in 
contusion.  In  complete  rupture  the  separated  portions  of  muscles 
should  be  approximated  by  posture  and  the  part  immobilized  in 
gypsum  from  four  to  six  weeks.  Operative  exposure  and  union  by 
deep  sutures  is  certain  in  its  results,  and  is  followed  by  a  rapid  return 
of  function.  The  sutured  muscle  should  be  immobilized  for  three 
weeks.  Repair  by  suture,  to  be  successful,  must  be  executed  early; 
delay  renders  apposition  of  the  separated  muscle  impracticable.  In 
neglected  cases  followed  by  permanent  loss  of  function,  muscle  flap 
transplantation  may  be  emploj'cd.  The  free  transplantation  of  por- 
tions of  muscles  has  not  been  followed  hj  improvement.  Massage  and 
active  motion  are  A-aluable  aids  in  after  treatment. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     565 

Open  Injuries  of  Fascia  and  Muscles. — These  are  classified  as 
incised,  lacerated  or  contused. 

The  consequences  of  injuries  of  this  class  depend  upon  the  dis- 
turbances of  function  they  cause  and  upon  the  occurrence  of  infection. 
The  former  are  slight  and  transient  in  cases  of  superficial  incised  or 
punctured  wounds,  unless  a  motor  nerve  happens  to  be  divided,  but 
are  likel3'  to  be  very  serious  when  the  injury  is  deep  and  produced  by 
a  scythe,  a  saber,  a  hatchet,  a  bayonet,  or  grenade  splinters  or  by  a 
tearing  force,  such  as  the  bites .  of  animals.  Torn  muscle  fiber  is 
exceedingly  susceptible  to  infection,  while  wounds  with  smooth  edges 
frequently  escape  it.  Small  stab  and  gunshot  wounds  are  also  un- 
likely to  infect,  and  when  left  undisturbed  frequently  heal  by  primary 
union. 

The  treatment  of  open  wounds  of  fascia  and  muscle  does  not  differ 
from  that  of  simple  wounds.  Incised  wounds  of  these  structures  should 
be  accurately  sutured.  Muscle  suture  should  be  executed  with  catgut 
and  dead  spaces  avoided.  The  four  puncture  suture  shown  in  Fig. 
43  will  be  found  useful  in  this  connection.  AVhen  primary  union  fol- 
lows carefully  made  repair,  complete  restitution  of  function  may  be 
expected.  "When  the  wound  is  not  a  fresh  one,  the  skin  should  not  be 
entireh^  closed,  but  iodoform  gauze  tamponade  employed  for  a  few 
days.  "When  infection  has  not  thus  been  obviated,  the  gauze  may  be 
removed  and  tube  drainage  inserted.  Contused  and  lacerated  wounds, 
such  as  occur  in  connection  with  compound  fractures,  may  be  trinnned, 
drained  and  approximated  with  interrupted  sutures.  Wounds  of 
several  days  standing  are  best  treated  by  the  open  method.  When 
sloughing  and  infection  have  disappeared,  secondary  apposition  of  the 
granulating  wound  surfaces  may  be  advantageously  practiced. 

Injuries  of  Tendons. — Subcutaneous  Injuries. — The  resistant  struc- 
ture of  tendons  and  the  protected  positions  they  occupy  render  their 
subcutaneous  contusion  comparatively  rare,  though  it  does  at  times 
occur  as  the  result  of  violent  crushing  force.  Crushing  of  a  tendon 
causes  it  to  fray  or  separate  into  its  component  fibers.  Where  tendons 
lie  in  apposition  with  bone,  blunt  force  may  cause  the  formation  of  a 
hematoma  in  the  tendon  sheath,  which  may  be  palpated  in  the  form 
of  hard  cords  that  move  with  the  tendon.  Active  motion  and  massage 
soon  remedy  the  condition. 

Fupture  of  tendons  occurs  less  frequently  than  rupture  of  the 
muscle  for  obvious  reasons.  Wlien  the  tendon  tears,  the  separation 
usually  occurs  where  the  tendon  is  inserted  into  the  hone  or  at  the 


566     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

point  where  the  muscle  hecomes  tendinous.  Often  a  portion  of  bone 
(avulsion  fracture)  or  a  portion  of  muscle  fiber  tears  off  with  the 
tendon. 

Rupture  of  a  tendon  usually  occurs  when  the  muscle  is  overstretched 
during  contraction,  though  it  may  happen  during  muscular  relaxation. 
In  a  certain  number  of  instances,  indirect  violence,  such  as  a  concom- 
itant dislocation,  may  cause  a  tendon  to  tear.  Tendons  subjected  to 
chronic  irritation  tear  easily  (fragilatas  tendinum).  Pathological 
loss  of  resistance  in  tendons  may  be  occupational  in  origin.  This  is 
illustrated  in  drummers  who  not  infrequently  rupture  the  tendon  of 
the  extensor  longus  pollicis  (Friedrich"). 

The  tendons  most  frequently  ruptured  are  those  of  the  quadriceps 
femoris  and  of  the  liceps  irachii.  Of  the  former,  rupture  of  the 
ligamentum  patellae  is  usually  attended  with  avulsion  of  a  portion  of 
the  tubercle  of  the  tibia  or  of  the  lower  edge  of  the  patella ;  the  quad- 
riceps tendon  may  tear  off  a  portion  of  the  upper  edge  of  the  patella 
or  may  tear  near  the  muscle  or  —  which  is  rare  —  rupture  transversely 
at  its  middle.  The  biceps  usually  tears  off  its  long  head  at  the  bone ; 
the  tendon  Achilles  at  its  insertion  into  the  os  calcis ;  and  the  triceps 
at  its  attachment  into  the  olecranon.  The  extensor  te^idons  of  the 
fingers  may  be  torn  from  the  distal  phalanges  when  these  are  forcibly 
flexed  while  the  fingers  are  held  rigid.  The  attachments  of  the  super- 
ficial and  deep  flexors,  together  with  portions  of  bone,  have  been 
separated  by  sudden  forcible  involuntary  contraction  of  the  muscles 
(Schlatter^"). 

The  rupture  of  a  tendon  is  often  attended  with  a  painful  snap. 
"When  this  is  followed  by  loss  of  function  of  the  dissociated  muscle  and 
a  faulty  position  of  the  part  from  contracture  of  the  apposing  muscles, 
and  when  palpation  reveals  a  depression  corresponding  to  the  normal 
location  of  the  tendon,  the  diagnosis  should  be  clear.  To  this  may  be 
added  that  the  muscle  whose  tendon  is  ruptured  does  not  respond  to 
efforts  at  motion  and  may  be  felt  as  a  flabby  mass  located  near  its  point 
of  origin.     Hemorrhagic  infiltrate  is  moderate  or  absent. 

The  treatment  consists  of  early  exposure  and  repair  hy  suture  of  the 
torn  tendon.  When  the  surgical  repair  is  accomplished,  the  part 
should  be  postured  to  obviate  strain  upon  the  line  of  suture,  and  immo- 
bilized in  this  position  for  from  four  to  six  weeks.  When  it  is  not 
feasible  to  approximate  the  torn  long  head  of  the  brachial  biceps,  the 
peripheral  portion  may  be  sutured  to  the  short  head  of  the  muscle 
with  the  assurance  that  little  or  no  appreciable  loss  of  function  will 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES    567 

obtain.  Avulsion  of  the  insertions  of  the  tendons  of  fingers  may  be 
treated,  by  simple  relaxation  posture  and  immobilization.  In  a  certain 
number  of  cases  treated  by  posture,  the  resultant  scar  stretches  and 
interferes  with  the  proper  forceful  action  of  the  muscle.  In  these  eases 
the  scar  may  be  dissected  out  and  secondary  repair  of  the  tendon  made, 
a  procedure  productive  of  gratifying  results  in  many  instances. 

Subluxation  of  a  tendon  is  a  term  used  when  a  tendon  leaves  its  bed 
after  its  sheath  and  confining  bands  are  ruptured. 

This  rare  condition  occurs,  at  times,  at  the  external  malleolus.  The 
peroneus  longus  or  both  peronei  are  dislocated  forward,  when  the 
retaining  ligament  is  torn  by  sudden  forcible  supination  of  the  foot. 
Dislocation  of  the  tendon  of  the  iihialis  posticus  has  been  reported. 
Dislocation  of  the  long  head  of  the  biceps  occurs  after  rupture  of  the 
tendon  sheath  and  the  joint  capsule,  together  with  aA'ulsion  of  the 
insertion  of  the  supraspinatus,  a  condition  of  affairs  at  times  coinci- 
dent to  dislocation  of  the  humerus.  Dislocation  of  the  extensor 
tendons  of  the  fingers  toward  the  ulnar  side  has  been  observed  in  con- 
nection with  rupture  of  the  bands  leading  to  the  radial  side  of  the 
carpus  (Schiirmayer^^).  A  similar  condition  occurs  in  connection 
with  chronic  articular  rheumatism,  which  is  believed  to  be  due  to 
stretching  of  the  connective  tissue  (Krukenberg^-). 

As  a  rule,  the  dislocated  tendon  may  be  palpated  in  its  abnormal 
position,  and  may  be  manipulated  into  its  proper  place.  In  a  certain 
number  of  cases  a  pad  and  a  plaster  bandage,  which  hold  the  tendon 
in  its  normal  position,  is  all  that  is  necessary.  "When  this  is  not  feas- 
ible, the  tendon  should  be  exposed  and  held  in  place  by  an  artificial 
bridge  fashioned  from  the  neighboring  connective  tissue.  For  the 
purpose  it  may  be  necessary  to  use  a  fascial  flap  or  a  portion  of  the 
periosteum  turned  down  from  the  malleolus. 

Open  Injuries  of  Tendons. —  "Wounds  which  completely  or  incom- 
pletely divide  tendons  frequently  occur  upon  the  hands  and  feet,  and 
are  usually  the  result  of  injuries  with  cutting  instruments  but  may 
result  from  tearing  b}^  machinery,  explosions  and  severe  contusions. 
Trauma  of  this  sort  is  often  complicated  by  injuries  to  nerves,  blood 
vessels,  bones,  and  joints.  The  condition  of  the  tendon  stumps  being 
either  smooth  or  crushed  or  fibrillated,  indicate  the  character  of  force 
which  has  produced  their  separation.  In  cases  of  avulsion  of  a  finger, 
the  entire  tendon  up  to  its  muscular  origin  may  be  torn  away.  Occa- 
sionally a  tendon  is  wound  about  a  rotating  drill  which  penetrates  a 
limb  and  the  tendon  is  pulled  out  in  iota.     The  ends  of  divided  tendons 


568     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


do  not  always  present  in  the  wound;  usually  the  central  end  is  re- 
tracted by  the  muscle  while  the  distal  portion  disappears  only  when 
the  posture  of  the  affected  part  causes  it  to  do  so. 

The  recognition  of  the  division  of  tendons  is  based  on  a  careful 
study  of  the  function  of  the  injured  part,  which  should  be  thoroughly 
carried  out  even  in  cases  of  small  stab  or  incised  wounds. 

The  fundamental  principle  in  the  treatment  of  divided  tendons  is 
that  of  immediate  repair  hy  suture,  and  should  be  carried  out  in  every 
instance  unless  the  character  of  the  injury  to  the  tendon  or  of  the 
wound  makes  this  impossible.  When  tendons  are  crushed  or  torn  so 
that  necrosis  of  their  substance  is  certain,  or  if  the  soft  parts  are  so 
traumatized  that  infec- 
tion is  to  be  expected,  it  ^ 
is  best  to  delay  operative 
efforts  at  repair  until 
these  elements  are  elim- 
inated from  the  problem. 
When  infection  already 
exists,  it  is  unwise  to 
make  search  for  the  re- 
tracted tendon  stump,  as 
the  manipulation  associ- 
ated with  the  attempt  is 
likely  to  spread  the  infec- 
tion along  the  tendon 
sheaths     and     provoke    menacing    phlegmonous     inflammation. 

In  these  cases  the  wound  should  be  treated  by  the  open  method  and, 
as  soon  as  granulation  is  established,  secondary  repair  of  the  tendons 
may  be  made  by  suture.  The  repair  should,  however,  not  he  delayed 
longer  than  is  yiecessary,  as  the  tendons  continue  to  retract  with  the 
muscle  belly  and,  as  time  goes  on,  can  no  longer  be  approximated. 

Incomplete  division  of  tendons  is  of  no  particular  significance  and 
is  not  recognized  except  during  repair  of  the  attendant  wound. 

Suture  of  tendons  should  be  preceded  by  v.  Esmarch's  exsanguina- 
tion  and  the  part  postured  so  as  to  relax  the  tendons,  i.  e.,  flexed  when 
the  flexors  are  divided  and  extended  when  the  extensors  are  to  be 
repaired.  The  peripheral  portion  of  the  tendon  usually  presents  in 
the  wound  at  once,  the  central  portion  may  be  "milked"  into  view 
by  firm  strokes  made  with  the  hand  or  gauze  pads.     At  times  the 


Fig.  187. —  a,  Tendon  Suture  after  Dryer;  &, 
Tendon  Suture  after  v.  Frisch. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     569 


central  stump  may  be  brought  into  view  with  a  small  tenaculum  car- 
ried into  the  tendon  sheath.  When  the  central  tendon  stumps  are 
strongly  retracted  it  is  necessary  to  expose  them  by  incision.  This 
should  be  made  to  the  side  of  the  tendon  sheaths  and  a  short  flap 
formed  with  the  view  of  obviating  adherence  to  the  subsequent  scar. 

In  old  cases  the  scar 
of  the  original  injury 
must  be  dissected  out 
before  search  is  made 
for  the  divided  tendons. 
When  a  tendon  stump 
is  found  it  shotdd  at 
once  be  anchored  with 
a  silk  suture  to  which  a 
clamp  may  be  attached. 
The  suture  may  subse- 
quently be  used  for  the 
purpose  of  uniting  the 
divided  tendon.  When 
a  number  of  tendons 
are  divided,  it  is  not 
always  easy  to  identify 
the  separated  ends. 
Correct  coaptation  rests 
on  a  knowledge  of 
anatomy  and  the  size 
and  position  of  the 
ends  of  the  tendons. 

The  ends  of  torn  ten- 
dons must  be  refreshed 
before  repair  is  at- 
tempted. 

When  the  related 
stumps  are  found  and 
identified,  the  anchor  suture  is  passed  through  the  peripheral  stump 
and  tied  with  the  part  so  postured  as  to  achieve  a  maximum  of 
relaxation,  of  the  muscle.  The  ends  of  the  tendons  must  be 
accurately  coaptated ;  lateral  approximation  does  not  accomplish  the 
purpose. 


Fig.  188. —  Tenoplasty. 

a,  Wolfler;  Z),  Hagler  (when  the  first  transverse 
suture  is  tied,  it  is  supplemented  by  two  or  more  lon- 
f^itudinal  sutures);   c-f,   Trunka's  method. 


570     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

Suturing  (tenorrhaphy)  is  best  performed  with  sublimated  silk. 
Of  the  various  methods,  that  of  Hagler  (Fig.  188,  b)  is  most  useful 
in  cases  of  division  of  small  tendons.  The  number  of  supplementary 
sutures  may  be  varied  with  the  degree  of  tension.  Wolflcr's  quilt 
suture  and  Trunka's  method  (Fig.  188)  are  more  complicated,  but 
give  very  satisfactory  results  when  properly  executed.  Lange's 
method  (Fig.  189)  and  those  of  Dryer  and  v.  Frisch  (Fig.  187)  are 
very  well  adapted  to  cases  of  secondary  repair.  Malewitch^^  considers 
the  methods  of  Lange  and  Hagler  of  the  greatest  service  when  much 
tension  is  necessary,  while  Kimura^*  prefers  the  sutures  of  v.  Frisch 
and  Dryer  for  the  purpose.  It  would  seem  fair  to  state  that  repeated 
practice  with  either  method  will  produce  the  desired  result. 

When  the  tendon  sheaths  are  injured  or  are  split  in  an  effort  to 
locate  the  retracted  stumps  of  tendons,  they  should  be  carefully 
approximated  with  fine  silk  sutures.  The  retaining  bands  of  the 
tendon  sheaths,  such  as  the  ligamentum  carpi  dorsale  et  volaris  should 
also  be  repaired  in  a  similar  manner. 

The  repair  of  ten- 
dons is  very  likely  to     ^  -^.-.c=r."-<=»:.-.   'i  =p  .•::£=>::.-:c=i-jtij 


be  followed  by  the  ad-    \cy  '^t^^^---' — ^---('j  =^ 

hesion  of  the  site  of  fig.   189.— Tendoi^   Suturing  after  Lange. 

union  to  the  sur- 
rounding tissues.  To  obviate  this  many  methods  of  procedure  have 
been  employed.  Of  these,  the  method  of  encasing  the  tendon  suture 
line  in  especially  prepared  tubules  of  gelatin  which  are  slowly  ab- 
sorbed would  seem  to  possess  considerable  merit  (Lotheisen^^).  The 
superficial  wound  should  be  closed  with  interrupted  sutures  which 
leave  small  interspaces  for  the  escape  of  fluid  secretions.  If  evidence 
of  inflammation  develops,  one  or  more  stitches  should  at  once  be  re- 
moved, and  if  the  inflammatory  process  is  not  arrested,  all  the  sutures, 
including  those  holding  the  tendons  in  apposition,  must  be  removed, 
the  wound  widely  opened  and  lightly  packed  with  iodoform  gauze. 
The  dressing  should  be  applied  so  that  there  is  no  tension  on  the 
sutures  (relaxation  dressing). 

Active  and  passive  motion  should  begin  on  the  fifth  day  following 
the  healing  of  the  wound.  Return  of  function  is  hastened  by  the' use 
of  warm  haths  and  massage.  The  degree  of  function  available  at  the 
end  of  about  eight  weeks  is  the  maximum  attainable  and  in  most  cases 
is  very  good. 

Healing  of  tendons,  of  defects  that  are  not  repaired  or  of  those  that 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES    571 


follow  tenotomij,  takes  place  by  the  formation  of  a  scar  mass  which 
results  from  the  organization  of  the  blood  clot  sequential  to  the  injury, 
the  proliferation  of  connective  tissue  from  the  tendon  sheaths  and 


^^^^^=^ 


Fig.  190. —  Tenoplasty,  after  Friedricii. 


the  ends  of  the  tendons.     This  mass  of  scar  tissue  ultimately  (in  about 
three  months)  takes  on  the  character  of  tendon  tissue  (Marchand^''). 

When  crushing  or  tearing  of  tendons  is  followed  by  loss  of  siib- 
stance,  their  central  ends  are  likely  to  be  widely  separated  from  the 
peripheral    stumps.      Two    forms    of    operative 
measures  are  available  for  purposes  of  relief,  i.  e., 
tenoplastij  and  tendon  transplantation. 

Tenoplasty  consists  of  filling  the  gap  between 
the  tendon  stumps  or  between  the  avulsed  tendon 
and  its  insertion  into  the  bone.  For  the  purpose, 
tendon  stumps  may  be  elongated  by  the  fiap 
method  shown  in  Fig.  190,  or  the  interspace  may 
be  bridged  with  strands  of  catgut  or  of  silk  (Fig. 
191)  w^hich  are  fastened  to  the  two  tendon  stumps 
or  to  the  bone  and  tendon.  When  the  operation  is 
followed  by  primary  union,  the  gap  is  gradually 
filled  with  freshly  proliferated  connective  tissue 
which  takes  on  a  round  form  and,  with  appro- 
priate after  treatment,  does  not  become  adherent  to  the  contiguous 
tissues  (Lange^').  In  situations  such  as  the  site  of  the  flexor  tendons 
of  the  fingers,  where  it  is  necessary  to  anchor  the  tendon  laterally,  the 
latter  method  does  not  accomplish  the  purpose.    In  cases  of  this  sort. 


Fig.  191. —  G  lIjck  's 
Method  of  Cat- 
gut "  Tendon 
Bridging." 


572     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


better  results  are  obtained  by  the  use  of  free  tendon  transplants  which 
may  be  derived  from  the  patient  himself  (for  instance  the  palmaris 
longus)  or  from  freshly  amputated  limbs. 

Tendon  transplantation  was  originally  devised  by  Nicoladoni^^  and 
perfected  by  Drobruk/^  Vulpius,-°  Hotfa,^^  and  Lange."  Tl:e  ohject 
of  the  procedure  is  to  transfer  the  power  of  a  healthy  muscle  to 

THE  tendon  of  A  USELESS  ONE  OR  TO  THE  POINT  OF  ITS  INSERTION. 

The  effort  at  relief  is  applicable  in  cases  of  defects  of  tendons,  of 
atrophied  muscles,  and  for  the  purpose  of  re-  ^  ^ 

establishing  function  lost  by  reason  of  the 
abGence  of  innervation. 

Usually  the  peripheral  portion  of  the  defec- 
tive tendon  or  of  the  paralyzed  muscle  is 
divided  and  sutured  to  the  side  of  the  tendon 
of  a  normal  muscle,  or  a  flap  is  fashioned 
from  the  lateral  aspect  of  the  tendon  of  the 
healthy  muscle  and  an  end  to  end  anastomosis 
is  made  (Fig.  192).  In  this  way  extensive 
defects  in  the  extensor  or  the  flexor  tendons 
in  the  hands  may  be  anastomosed  with  neigh- 
boring tendons,  and  good  functional  results 
obtained. 

In  periosteal  tendon  transplantation 
(Lange^^)  the  peripheral  tendon  stump  of  the 
useless  muscle  is  not  utilized.     Instead,   an 


Pig.  192.—  Tendon  Trans- 
planting. 


In  Fig.  xi  the  peripheral 
stump     of     the     defective 
„,,.,,,  .      (paralyzed)       or      divided 

entire,   or   a   portion   ot,   healthy   tendon   is  tendon    (a)    is   implanted 

pushed  beneath  the  fascia  and  sutured  to  the  i"to_the  dde  of  the  healthy 

.  p    -,       .  .  p     ■,       contiguous  tendon  (o).   In 

periosteum  at  the  site  of  the  insertion  or  the  Fig.    b    a    flap    of    the 

useless  muscle.    In  some  instances,  the  healthy  li^::tltli.y   tendon   is   united 

with    the    peripheral     (de- 
muscle  has  been  connected  with  the  periosteum  fective)  stump. 

by  means  of  a  bridge  composed  of  catgut  or 

silk  in  the  same  manner  as  is  employed  in  connection  with  the  bridg- 
ing of  large  defects  of  tendons  (Lange^'') . 

Following  operative  efforts  at  relief,  the  part  should  be  immobilized, 
with  the  muscles  relaxed,  for  one  or  two  weeks  when  active  and  passive 
motion  should  be  begun.  Immobilization  for  longer  periods  of  time 
results  in  adherence  of  surrounding  parts  to  the  area  of  repair,  which 
seriously  jeopardizes  a  favorable  outcome. 

Injuries  of  Tendon  Sheaths  and  Bursae. —  Contusions  and  lacerations 
of  tendon  sheaths  are  followed  bv  extravasation  of  hlood  palpable  in 


:^IECHAXICAL  INJURIES  OF  DIFFERENT  TISSUES     573 

the  form,  of  teuse,  fiuetuathig  card-like  or  circumscribed  swellings 
which  are  very  painful  on  motion.  As  a  rule,  immobilization  of  the 
part  by  means  of  a  compression  bandage  maintained  for  a  week  is 
followed  by  return  to  the  normal. 

The  extravasation  of  hlocd  into  a  bursa  is  likely  to  be  followed  by 
chronic  inflammation  of  the  lining  membrane.  Persistent  irritation 
of  a  bursa  results  in  the  formation  of  a  so-called  hygroma. 

Open  injuries  of  tendon  sheaths  and  hursae  are  often  followed  by 
infection  which  rapidly  extends  to  contiguous  bursae  and  tendon 
sheaths.  Wounds  of  this  nature  should  be  treated  with  great  care  as 
regards  asepsis.  TVhcn  infection  occurs,  free  incision  and  drainage 
should  be  promptly  executed. 

Injuries  of  Peripheral  Nerves. —  Injuries  of  peripheral  nerves  are 
followed  by  complete  or  incomplete  interference  with  their  power  of 
conduction  (motion,  sensation,  reflexes,  vasomotor  and  trophic  influ- 
ences). The  degree  of  disturbance  is  dependent  upon  the  extent  of 
the  changes  in  the  nerve  fibere.  Moderate  modification  of  function 
indicates  injury  to  the  medullary  sheaths;  destruction  of  axis  cylin- 
ders is  followed  by  severe,  prolonged  or  permanent  loss  of  function. 

SuBCUTAXEOus  IxjURiES. —  Subcutancous  injuries  of  nerves  are 
divided  into  concussion,  contusion,  laceration,  and  subluxation. 

Concussion  of  nerves  follows  the  application  of  blunt  force  which 
may  be  directed  against  the  nerve  itself  (ulnar  nerve  at  elbow)  or  in 
the  area  of  its  distribution,  for  instance,  by  a  blow  or  fall  upon  the 
feet.  The  disturbances  which  occur  in  this  connection  are  transient 
and  are  followed  by  return  of  function  in  a  few  minutes  (p.  554). 
Severe  nerve  concussion  occurs  as  a  part  of  general  shock. 

Mild  forms  of  nerve  contusion  occur  in  so-called  pressure  paralysis, 
which  follows  compression  of  a  nerve  (especially  the  ulnar,  radial, 
and  sciatic)  during  sleep.  This  condition  usually  disappears,  return 
of  function  being  attended  with  a  peciUiar  feeling  of  tingling. 
Pressure  paralysis,  at  times,  follows  narcosis  during  which  the  nerve 
is  compressed  against  the  side  of  the  operating  table,  or  the  head  of 
the  humerus  is  pressed  against  the  musculospiral  nerve  when  the 
arms  of  the  patient  are  abducted  during  maintenance  of  the  Trende- 
lenburg posture.  Paralysis  produced  in  this  way  may  last  for  several 
weeks.  Contusion  of  the  sciatic  nerve  and  subsequent  disturbances 
of  innervation  may  follow  undue  stretching  of  the  ner\'e  during  reduc- 
tion of  dislocations  at  the  hip  joint.  The  faulty  (too  tight)  applica- 
tion of  the  V.  Esmarch  bandage  or  of  immobilizing  bandages  are  also 


574     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

followed  by  nerve  paralysis.  Pressure  exerted  by  callous  formation 
following  a  fracture  (musculospiral  in  the  arm,  ulnar  at  the  elbow, 
and  peroneal  at  the  upper  end  of  the  fibula)  often  results  in  nerve 
paralysis  which  is  permanent,  unless  the  nerve  is  freed  by  operative 
means.  A  similar  condition  of  affairs  follows  the  inclusion  of  a  nerve 
trunk  in  scar  tissue  following  infection,  especially  when  a  fragment  of 
broken  bone  is  included  in  the  scar.  Occasionally,  tumors  make  pres- 
sure upon  nerve  trunks  and  cause  abolition  of  their  conductivity. 
The  sudden  occurrence  of  a  moderate  degree  of  contusion  of  a  nerve 
produces  symptoms  closely  allied  to  nerve  concussion,  which  soon  dis- 
appear; however,  when  powerful  hlunt  force  is  directed  against  a 
nerve  trunk  by  a  fall  or  by  a  fractured  or  dislocated  tone,  permanent 
destruction  of  nerve  function  may  be  the  result.  This  is  also  true 
when  nerves  are  stretched  or  torn  in  connection  with  fractures  and 
dislocations.  In  this  way  the  nerves  of  the  arm  are  injured  in  dislo- 
cations at  the  shoulder  joint,  or  the  cranial  nerves  are  traumatized  at 
their  points  of  exit  in  eases  of  fracture  of  the  base  of  the  skull.  The 
latter  injury  is  not  uncommonly  followed  by  paralysis  of  one  or  more 
divisions  of  the  trifacial  nerve,  the  seventh,  the  auditory,  or  the  optic 
nerve. 

Nerve  injuries  are  recognized  with  comparative  ease.  The  diagnosis 
rests  on  the  loss  of  function  and  the  localization  of  the  injury. 

Confusion  may  arise  in  connection  with  the  rupture  of  muscles, 
ischemic  paralysis,  and  muscle  paralysis  following  injury  and  inflam- 
matory conditions  of  joints.  The  differentiation  is  based  on  the 
absence  of  sensory  disturbances  and  of  the  reaction  of  degeneration, 

Restoration  of  function  depends  upon  the  extent  of  injury,  upon  the 
regenerative  capacity  of  the  nerve,  and  upon  whether  conditions  favor- 
able to  regeneration  are  created. 

The  treatment  of  subcutaneous  contusions  and  lacerations  of  nerves 
should  be  primarily  conservative.  That  is,  the  affected  part  is  immo- 
hilized  in  an  appropriate  gypsum  dressing  with  the  view  of  obviating 
additional  injury  to  the  nerve  by  the  movements  of  muscles. 

Mild  electrical  stimulation  may  be  employed  at  once.  For  the  pur- 
pose, the  galvanic  current  is  used ;  the  anode  is  placed  over  the  plexus 
and  the  cathode  over  the  site  of  the  injury. 

Incomplete  loss  of  function  of  the  part  supplied  by  the  injured 
nerves  justifies  the  assumption  that  it  is  not  entirely  divided.  In 
cases  of  this  sort  recovery  follows  the  treatment  indicated  above  in  a 
few  weeks.    When,  however,  the  clinical  picture  indicates  complete 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     575 

solution  of  continuity  of  the  nerve  and  no  improvement  of  symptoms 
develops  at  the  end  of  four  to  six  weeks,  operative  efforts  at  relief 
should  no  longer  be  delayed.  The  longer  operative  measures  are  post- 
poned the  less  likely  is  a  successful  outcome.  The  exposed  nerve  is 
usually  found  imbedded  in  a  mass  of  newly  formed  scar  tissue,  or  its 
divided  ends  are  more  or  less  widely  separated  and  the  interspace 
filled  with  scar  tissue.  The  bulbous  ends  of  the  ner^^e  trunk  are 
refreshed  or  the  portion  of  the  nerve  which  has  undergone  degenera- 
tion is  resected  and  nerve  suture  or  neuroplasty  is  performed  in  accord 
with  the  rules  laid  down  below. 

In  cases  of  pressure  paralysis  due  to  hone  callus  or  scar  tissue  the 
nerve  must  be  dissected  free  from  its  environment  (neurolysis),  and, 
after  the  necessary  repair  is  made,  it  should  be  surrounded  by  a 
fascial  fat  transplant  derived  from  the  contiguous  parts.  If  the  nerve 
has  not  entirely  lost  its  electrical  excitability,  evidence  of  return  of 
function  is  manifested  in  a  few  days.  "When  there  is  doubt  as  to  the 
conductivitj'  of  the  nerve,  neurolysis  may  be  practiced,  and  if  this  is 
not  followed  by  return  of  function,  the  injured  area  may  be  resected 
and  secondary  repair  performed  (Schede^^). 

Suhluxation  of  nerves  is  rare  and  is  practically  limited  to  the  uhiar 
and  peroneal  nerves.  The  former  occurs  in  connection  with  fracture 
of  the  internal  condyle  of  the  humerus,  the  latter,  with  fracture  of  the 
upper  end  of  the  fibula.  The  \ilnar  nerve  maj^  be  displaced  as  the 
result  of  a  sudden  forcible  flexion  of  the  forearm,  when  the  epicond^'le 
is  underdeveloped  or  the  nerve  is  not  well  surrounded  by  confining 
bands  of  fibrous  tissue.  This  condition  may  also  be  hahitual  or  con- 
genital. Under  these  conditions  the  subluxation  occurs  with  every 
flexion  of  the  forearm  or  with  each  contracture  of  the  triceps  muscle. 
Fortunately  the  phenomenon  is  not  attended  with  serious  disturbances 
(Momburg^^). 

Symptoms  of  nerve  subluxation  arise  when  the  displacement  is 
traumatic  in  origin,  and  then  only  when  the  nerve  is  contused  or 
inflamed.  The  diagnosis  rests  on  the  pain  in  the  area  of  distribution 
of  the  nen^e,  motor  or  sensory  disturbances,  and  palpation  of  the  nerve 
trunk  in  its  faulty  position. 

In  cases  of  subluxations  of  nerves  associated  with  symptoms,  the 
treatment  consists  of  exposure  of  the  nerve  and  replacement  in  its 
normal  position,  where  it  may  be  held  by  means  of  a  pediculated 
muscle  flap  (Momburg^^).     In  recent  subluxations  of  the  ulnar  nerve, 


576     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

an  attempt  may  be  made  to  cause  its  adherence  in  its  normal  position 
by  immobilizing  the  arm  in  full  extension  for  several  weeks. 

Open  Injuries  of  Nerves. —  Wounds  extending  into  the  deeper 
tissues  may  be  complicated  by  complete  or  incomplete  division  of  nerve 
trunks.  The  character  of  nerve  wounds  does  not  differ  from  that 
pertaining  to  soft  parts  generally,  i.  e.,  incised,  perforating,  contused, 
lacerated,  gunshot,  etc.  Nerves  are  often  injured  by  the  rough  edges 
of  bones  which  penetrate  the  tissues  in  compound  complicated  frac- 
tures. Portions  of  splintered  bones  or  foreign  bodies,  such  as  frag- 
ments of  glass,  wood  or  metal,  projectiles,  etc.,  are,  at  times,  imbedded 
in  nerve  trunks,  and  the  consequent  proliferation  of  connective  tissue 
destroys  (by  pressure)  what  remains  of  the  normal  nerve  tissue  and 
complete  loss  of  function  is  ultimately  established.  Occasionally  a 
ligature  is  applied  to  a  nerve  during  an  operation  with  consequent 
loss  of  function.  Explosions,  injuries  by  machinery,  or  the  tearing 
force  of  grenade  splinters  often  result  in  the  avulsion  of  extensive 
sections  of  nerve  trunks. 

The  stumps  of  nerves  divided  by  cutting  instruments  do  not  sep- 
arate widely,  though  their  edges  are  never  smooth,  as  bundles  of  nerve 
fibers  protrude  from  cut  ends.  Contused  nerves  can  be  readily  recog- 
nized by  the  red  discoloration  found  at  the  site  of  injury. 

The  character  of  injury  which  divides  a  nerve  has  no  determining 
influence  on  the  sequential  events.  In  each  instance,  nerve  degenera- 
tion follows.  This  degeneration  takes  place  at  the  site  of  itijury 
{traumatic  degeneration)  in  from  two  to  four  days,  and  is  soon  fol- 
lowed by  secoyidary  (paralytic)  degeneration  of  the  entire  nerve  peri- 
pheral to  the  point  of  section  and,  to  a  slight  extent,  central  to  it. 
Direct  union  and  immediate  reestablishment  of  nerve  conductivity  is 
not  possible.  Reactivation  of  a  sectioned  nerve  or  of  one  sufficiently 
contused  to  abolish  its  function  occurs  only  after  a  prolonged  and 
complicated  regenerative  process. 

The  beginning  of  nerve  regeneration  is  indicated  by  the  enlargement 
of  the  nuclei  of  the  cells  of  the  neurolemma  and  the  formation  of 
numerous  karyokinetic  figures.  Degeneration  of  the  medullary  sub- 
stance is  attended  with  the  appearance  of  myelin  fragments,  while  the 
axis  cylinders  undergo  fibrillation.  The  formation  of  new  axis  cylin- 
ders and  the  replacement  of  the  medullar}^  sheaths  would  seem  to  be 
associated  with  these  proliferative  prenomena  (Marchand,^*  and 
others),  though  there  is  no  unity  of  opinion  regarding  it,  many 
observers  believing  that  regeneration  takes  place  from  the  divided 


IVIECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     577 

axis  cylinders,  a  view  borne  out  by  observations  made  in  connection 
with  tissue  culture  (Ingcbrigtsen-^), 

The  newly  developed  nerve  fibers  appear  first  in  the  central  stump, 
where  they  are  connected  with  the  older  ones.  Under  favorable  con- 
ditions these  fibers  penetrate  the  nerve  sheatLs  in  the  area  of  granula- 
tion tissue  at  the  site  of  the  injury  and  grow  on  toward  the  periphery, 
following  the  course  of  the  degenerated  fibers,  and  ultimately  extend 
over  the  entire  distribution  of  the  nerve;  at  least  this  is  one  theory 
of  nerve  regeneration  {Wallerkui  Jaw),  a  view  supported  by 
Marchand,-*  and  others.  Margulies-*^  and  his  followers  maintain  that 
regeneration  also  takes  place  in  the  peripheral  portion  of  the  nerve, 
but  that  the  anatomical  elements  concerned  in  this  proliferation  do 
not  take  on  the  true  aspects  of  conducting  nerA-e  elements  until  joined 
with  the  fibers  originating  in  the  central  portion  of  the  nerve. 

Repair  and  regeneration  as  described  takes  place  when  the  wound  is 
not  infected,  when  the  nerve  is  not  completely  divided,  when  the  nerve 
stumps  lie  in  close  apposition,  or  when  contusion  of  nerve  is  moderate 
in  degree. 

On  the  other  hand,  union  of  divided  nerve  ends  docs  not  occur  when 
infection  develops  and  a  large  quantity  of  connective  tissue  is  depos- 
ited between  the  nerve  stumps,  when  a  large  area  of  the  nerve  is 
contused,  when  the  ends  of  the  nerves  are  separated  by  the  inter- 
position of  foreign  bodies  (portions  of  muscle,  fragments  of  bone,  etc.), 
or  when  the  stumps  are  widely  separated  by  the  force  which  produces 
the  injury. 

Under  the  last  condition,  the  central  end  of  the  nerve  undergoes 
bulbous  enlargement  and  the  peripheral  portion  is  gradually  absorbed 
and  replaced  by  connective  tissue. 

The  muscles  supplied  by  degenerated  nerves  slowly  atrophy 
(neurogenous  muscle  atrophy). 

Nerves  experimentally  separated  to  the  extent  of  several  centimeters 
will,  at  times,  unite  spontaneously.  The  bridging  of  defects  in  nerve 
trunks  by  means  of  decalcified  bone  tubules,  sterile  portions  of  arteries, 
strands  of  catgut,  and  by  the  use  of  portions  of  veins  (Ramsauer,-^ 
and  others)  has  succeeded  both  experimentally  and  clinically.  How- 
ever, efforts  of  this  sort  are  often  attended  with  failure,  more  espe- 
cially when  motor  or  mixed  nerves  are  injured.  On  the  other  hand, 
the  division,  injury  or  partial  excision  of  sensory  nerves  is  often  fol- 
lowed by  the  reestablishment  of  function.  This  is  well  illustrated  in 
connection  with  operative  efforts  directed  toward  the  relief  of  neu- 


578     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

ralg'ia  of  the  fifth  cranial  nerve,  and  is  especially  marked  in  cases  of 
division  of  the  sensory  nerves  of  the  fingers. 

The  symptoms  of  nerve  injnry  are  immediately  manifested  and 
vary  in  accord  with  the  function  of  the  nerve  involved,  i.  e.,  the 
division  of  mixed  nerves  is  followed  by  loss  of  motion  and  sensation. 
These  are  ultimately  followed  by  vasomotor  and  trophic  disturbances. 
Pain  and  paresthesia  are  also  more  or  less  present,  especially  when 
nerves  are  not  completely  divided. 

The  diagnosis  of  nerve  injuries  rests  on  the  anatomical  location  of 
the  injury  or  the  scar,  and  on  the  recognition  of  motor  and  sensory 
disturbances. 

Motor  disturbances  consist  of  paralysis  (and  lessening  of  reflexes) 
and  the  rapid  atrophy  of  certain  groups  of  muscles.  When  isolated 
branches  of  nerves  are  divided,  the  diagnosis  is  not  so  easily  made,  as 
restricted  muscular  paralysis  may  be  concealed  by  the  action  of  asso- 
ciated muscles  for  some  time  after  receipt  of  the  injur}'. 

For  this  reason,  the  electrical  reaction  of  nerves  should  be  tested  in 
cases  in  which  nerve  injury  is  suspected.  The  faradic  and  galvanic 
excitability  of  a  divided  nerve  gradually  disappears  and  usually  is 
absent  at  the  end  of  twelve  days  following  the  injury.  The  excit- 
ability to  faradic  stimulation  of  the  muscles  supplied  by  the  nerve 
disappears  in  about  the  same  time.  Within  two  weeks,  however,  the 
reaction  of  degenerating  muscle  to  the  galvanic  current  is  intensified 
and  the  reaction  of  degeneration  develops  —  the  anodal  closing  con- 
traction being  greater  than  the  cathodal  closing  contraction.  This 
reaction  reaches  its  height  in  from  three  to  four  months.  Sometimes 
the  increased  response  to  the  galvanic  current  does  not  disappear  until 
atrophy  of  the  muscles  is  complete  (about  a  year). 

The  healthy  muscles  apposed  to  those  paralyzed  gradually  shorten 
so  that  contracture  deformities  ultimately  develop. 

The  sensory  disturhances  following  injuries  of  mixed  or  sensory 
nerves  do  not  correspond  to  their  anatomical  distributions.  This  is 
due  to  the  liberal  anastomosis  which  exists  between  sensory  nerves  and 
because  new  nerve  elements,  derived  from  contiguous  nerves,  grow 
into  the  anesthetic  area  and  take  up  the  lost  function.  Consequently, 
permanent  loss  of  function  is  usually  restricted  to  small  areas  of  the 
surface  of  the  body.  Permanent,  complete  loss  of  sensation  over  large 
areas  follows  division  of  several  nerve  trunks  or  of  a  plexus  (Kol- 
liker,28  Schede22). 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     579 

Vasomotor  disturbances  are  expressed  by  redness,  cyanosis,  and 
lessening  of  temperature  of  the  skin. 

Trophic  disturbances  are  most  evident  in  the  skin,  and  consist  of 
dryness,  a  tendency  to  eczema,  herpes  zoster,  and  ulceration  and 
atrophy  of  the  nails.  In  some  instances,  the  hones  become  atrophic 
or  their  growth  is  delayed  and,  in  a  certain  number  of  cases,  the  joints 
are  filled  with  a  serous  exudate  and  ultimately  become  ankylosed. 

In  a  certain  proportion  of  cases,  open  and  subcutaneous  injuries  of 
nerves  are  followed  by  neuralgia  and  chronic  neuritis.  The  former 
condition  is  ascribable  to  nerves  that  are  subjected  to  pressure,  are 
only  partially  divided,  contain  foreign  bodies,  or  are  still  surrounded 
by  scar  tissue  after  regeneration  has  taken  place.  Neuritis  follows 
open  injuries  of  nerve  trunks  when  infection  occurs,  or  w^hen  inflam- 
mation is  provoked  by  foreign  bodies;  and  at  times  it  is  sequential  to 
subcutaneous  contusion  of  nerves. 

The  treatment  of  open  injuries  of  nerves,  in  fresh  cases,  is  operative. 
After  careful  cleansing  of  the  part,  the  injured  nerve,  either  com- 
pletely or  partially  divided,  is  freely  exposed  —  the  wound  being 
enlarged  if  necessary  —  and  carefully  repaired  by  suture.  In  cases 
of  extensive  contusion  and  laceration  of  the  soft  parts,  primary  nerve 
suture  should  be  performed  unless  the  extent  of  the  loss  of  nerve 
substance  makes  this  impossible.  In  gunshot  wounds,  however,  it  is 
best  to  delay,  especially  when  the  injury  is  produced  by  projectiles  of 
small  caliber.  In  cases  of  this  sort  the  nerve  may  not  be  entirely 
severed  and  recovery  will  follow  the  emplojTnent  of  the  conservative 
treatment  (p.  574).  If  no  improvement  occurs  at  the  end  of  two 
weeks,  the  nerve  may  be  exposed  and  treated  in  the  manner  employed 
in  cases  of  secondary  repair. 

The  suturing  of  nerves  in  cases  of  secondary  repair  should  be  pre- 
ceded by  refreshing  the  respective  stumps.  For  the  purpose  a  sharp 
knife  should  be  used;  the  use  of  scissors  (which  crush  the  delicate 
nerve  tissues)  should  be  avoided.  The  nerve  section  should  be  made 
squarely  and  all  connective  tissue,  including  the  bulbous  neuroma  of 
the  central  stump,  must  be  removed,  the  nerve  ends  must  be  accu- 
rately coapted,  strict  asepsis  must  be  observed,  and  tension  after  suture 
avoided.  Direct  suture,  in  which  fine  catgut  traverses  the  nerve 
stumps,  gives  the  best  results.  In  the  repair  of  slender  nerve  trunks 
the  entire  thickness  of  the  nerve  must  be  traversed ;  in  the  larger 
nerves,  the  suture  punctures  'may  be  restricted  to  the  outer  layers, 
thus  obviating  injury  to  the  more  centrally  located  fibers.  Fine  round 


580    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


needles  should  be  used  in  making  the  repair  to  prevent  the  injury  to 
the  nerve  produced  by  cutting  needles.  The,  so-called,  indirect 
method  of  nerve  suture  does  not  traumatize  the  fibers,  but  it  does  not 
accomplish  accurate  apposition  of  the  stumps.  It  consists  of  intro- 
ducing two  or  four  fine  sutures  into  the  paraneural  connective  tissue 
and  bringing  the  stumps  together  in  this  way. 

Several  methods  of  procedure  are  employed  with  the  view  of  pre- 
venting the  formation  of  adhesions  between  the  site  of  nerve  repair  and 
the  contiguous  tissues,  which  is  often  responsible  for  pain  and  disturb- 
ances of  function.  For  the  purpose  Payr-^'  encases  the  site  of  nerve 
union  in  magnesium  tubules ;  Lotheisen^^  uses  gelatin  tubes  hardened 
in  formalin ;  Forametti,^'"  sterile  portions  of  arteries  and  veins  derived 
from  calves.  .  The  tubules 
are  first  slipped  over  one 
stump  and,  after  the  repair 
is  made,  slid  into  place  over 
the  line  of  suturing.  The 
arteries  and  veins  are  split 
longitudinally  and  wrapped 
around  the  repaired  nerve 
trunk.  The  method  of 
wrapping  the  site  of  repair 
in  fresh  fat  transplants  is, 
at  this  writing,  regarded  as 
productive  of  the  best  re- 
sults. 

For  the  secondary  sutur- 
ing of  nerves,  v.  Bruns^^ 
(Gleiss^^)  recommends  longitudinal  sectioning  of  the  cicatricial  bridge 
and  union  of  the  nerve  trunk  as  shown  in  Fig.  193,  a,  b,  with  the  view 
of  approximating  nerve  fibers  capable  of  regeneration.  In  cases  of 
separation  of  the  nerve  stumps,  the  bulbous  central  stump  is  subjected 
to  inverted  V-shaped  excision,  the  peripheral  stump  is  trimmed  to  a 
wedge  shape  and  union  is  accomplished  by  suture  in  the  manner  shown 
in  Fig.  194. 

When  a  considerable  area  of  a  nerve  trunk  is  destroyed,  efforts  at 
union  are  attended  with  great  difficulty. 

Defects  three  centimeters  in  size  may  be  overcoyne  by  careful  trac- 
tion on  the  nerve  stumps;  when  this  is  not  feasible,  posture  relaxation 
may  be  resorted  to;  for  instance,  flexion  at  the  elbow  joint  and  knee. 


Fig. 


a 

193. —  Secondary  Nekve  Suture  ac- 
cording  TO   VON   BrUNS. 

a,  Longitudinal  incision  in  the  scar  in  the 
nerve,  -which  in    (6)   is  sutured  transversely. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES    581 


In  this  way  the  ends  of  the  nerves  may  be  approximated  and  repair 
by  suture  made  in  the  usual  way.  The  part  is  immobilized  in  the 
necessary  position  for  four  weeks  and  then  gradually  permitted  to 
assume  the  normal  range  of  motion.  In  selected  cases  it  is  justifiable 
to  resect  portions  of  bone  so  as  to  shorten  the  limb  to  the  extent 
necessary  to  make  repair  of  the  nerve. 

Ncuroplasty  is  a  method  of  nerve  repair  in  which  a  flap  is  fashioned 
from  the  central  or  from  both  stumps  of  the  nerve  and  brought 
together  by  suturing.  The  flap  method  of  bridging  defects  in  veins 
has  been  successful  (Tillmanns^^).  Filling  the  gap  with  foreign  mate- 
rial, such  as  decalcified  bone  tubules  or  catgut,  and  the  use  of  portions 
of  nerves  from  animals  has  also  been  followed  b}^  return  of  function, 
though  the  percentage  of  cases  attended  with  success  is  small. 

Nerve  grafting  consists  of  anastomosing  the 
peripheral  stump  of  a  divided  nerve  with  a 
contiguous  healthy  one,  and  was  first  carried 
out  by  Letievant^*  {{jreffe  nerveuse).  For  the 
purpose  the  peripheral  stump  may  be  sewed 
into  a  longitudinal  slit  made  in  the  trunk  of 
the  healthy  nerve  or  a  T-shaped  anastomosis 
may  be  made.  Restoration  of  function  has 
followed  lateral  anastomosis  without  refresh- 
ing the  nerves  at  the  site  of  union.  Partial 
return  of  function  has  followed  union  of  a 

Fig.  194 Suture  of  the  peripheral  portion  of  an  injured  median  nerve 

Pointed  Peripheral  with  a  normal  ulnar  nerve;  and  similar  re- 

EXD  OF  THE  XERVE  INTO  ,.      ,  j.    ,,  -,  .  p  .      .  ,       , 

THE  Proximal  End.  suits  have  loilowed  union  or  an  injured  ulnar 
with  a  healthy  median  nerve,  an  injured 
radial  with  a  pediculated  flap  dissected  from  the  median,  the  peri- 
pheral portion  of  a  paralyzed  facial  with  the  spinal  accessory  (Hack- 
enbruch,^^  Cushing,^**  Ballance  and  Stewart^")  or  with  the  hypoglossal 
(Korte,^^  Frazier,^^  and  others). 

In  cases  of  secondary  repair  of  7ierves,  the  superficial  wound  may 
always  be  closed ;  in  primary  cases,  the  character  and  co7idition  of  the 
wound  (with  respect  to  cleanliness)  decide  the  question.  When  it  is 
impracticable  to  entirel}'  close  the  wound,  the  soft  parts  immediately 
contiguous  to  the  repaired  nerve  should  be  apposed  in  order  to  afford 
as  much  protection  to  the  zone  of  repair  as  is  consistent  with  the 
conditions. 

Afler  the  wound  is  dressed  the  part  should  be  immobilized  for  sev- 


582     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

eral  (three  to  four)  weeks  in  a  position  which  obviates  tension  on  the 
suture.  At  the  end  of  tliis  time  electrical  stimulation,  massage  and 
active  and  passive  motion  may  be  cautiously  begun. 

Return  of  sensation  is  the  first  sign  of  a  successful  outcome,  though 
this  may  be  due  to  innervation  from  contiguous  nerves  and  must  be 
borne  in  mind.  Return  of  sensation  is  followed  by  the  disappearance 
of  the  reaction  of  degeneration,  then  by  response  to  galvanic  and 
faradic  excitation,  and  finally  by  return  of  voluntary  motion. 

The  time  required  for  return  of  function  varies  very  widely.  It 
returns  sooner  after  primary  than  after  secondary  repair.  The  more 
distant  from  the  nerve  centers  is  the  site  of  injury,  the  sooner  return 
of  function  follows  repair  (Etzold").  The  results  of  plastic  repair 
of  nerves  do  not  become  manifest  for  a  long  time. 

Suture  of  nerves  is  followed  by  return  of  sensation  in  from  two  to 
four  weeks.  Motion  may  begin  to  return  in  from  six  to  eight  weeks, 
but  has  returned  as  late  as  a  year  after  repair  of  the  nerve. 

A  compilation  of  reported  results  would  seem  to  show  partial  or  com- 
plete return  of  function  in  two  thirds  of  the  cases.  Favorable  out- 
come follows  secondary  repair  about  as  often  as  it  does  the  primary, 
although  delay  lessens  the  likelihood  of  a  favorable  outcome ;  return 
of  function  has  followed  resection  and  repair  of  a  nerve  injury  of 
fourteen  years'  standing. 

"When  function  fails  to  return  the  area  of  repair  should  be  again 
exposed,  the  scar  tissue  excised,  the  nerve  ends  refreshed,  and  another 
attempt  made  to  effect  union  and  regeneration. 

Injuries  of  Blood  Vessels, —  Subcutaneous  Injuries  of  Large  Blood 
Vessels. —  Subcutaneous  injuries  of  large  blood  vessels  occur  in  con- 
nection with  contusions  and  lacerations  of  tissue.  Comparatively 
moderate  force  traumatizes  diseased  vessels,  especiall}^  those  that  have 
become  sclerotic  or  are  infected  or  have  been  subjectd  to  pressure  by 
neoplasms  for  a  long  time. 

Injuries  to  blood  vessels  occur  from  external  violence,  or  from  dis- 
located bones ;  or  they  may  be  traumatized  during  the  reduction  of  a 
dislocation  (especially  old  dislocations). 

The  immediate  and  remote  effects  of  trauma  upon  blood  vessels 
depends  upon  the  degree  of  force  to  which  thej^  are  subjected  and  upon 
the  resistance  of  their  various  coats.  Comparatively  slight  force 
traumatizes  the  intima  and  is  followed  by  a  superficial  or  deep  solution 
of  continuity  of  endothelium,  where  a  tiny  thrombus  rapidly  forms 
which  is  soon  followed  by  healing. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     583 

In  cases  of  more  severe  iujury,  for  instance,  when  the  media  is  torn, 
the  resultant  scar  may  dilate  under  the  i^ressure  of  the  circulating 
fluid  and  the  formation  of  a  true  traumatic  aneurism  be  the  result. 
Extensive  contusions  of  arteries  and  veins,  especially  when  the  intima 
is  detached,  are  followed  by  the  formation  of  mural  or  obliterating 
thrombosis.  Crushing  of  the  intima  of  a  blood  vessel  without  injury 
to  the  more  resisting  adventitia  produces  an  effect  similar  to  angio- 
tripsy,  and  is  followed  b}^  the  formation  of  a  thrombus.  "When  deal- 
ing wdth  large  blood  vessels  it  is  not  safe  to  rely  upon  the  angiotribe 
for  the  permanent  control  of  hemorrhage,  especially  when  ligatur©  of 
the  vessels  accomplishes  the  desired  result  with  certainty. 

Complete  division  of  hlood  vessels  may  be  transverse,  or  oblique, 
or  loss  of  substance  of  a  portion  of  the  wall  of  a  vessel  may  occur. 
The  latter,  though  attended  by  profuse  bleeding,  ma}'  be  followed  by 
healing  of  the  wall  of  the  vessel  by  its  occlusion,  by  an  obliterating 
thrombus,  or  by  the  formation  of  a  pulsating  hematoma  {traumatic 
false  aneurism).  Complete  tearing  or  crushing  of  an  artery  is  fre- 
quently spontaneously  closed  by  retraction  and  contraction  of  the 
open  ends. 

Subcutaneous  injury  of  large  blood  vessels  varies  widely  in  extent, 
especially  in  the  extremities,  where  they  are  frequently  exposed  to 
crushing  force,  or  are  lacerated  in  efforts  at  reduction  of  dislocations, 
or  in  attempts  to  reduce  malposition  of  bone  fragments  following 
fracture.  Blunt  force  applied  to  the  abdomen  (a  kick  from  a  horse 
or  a  blow  from  a  wagon  shaft)  at  times  crushes  the  mesentery  against 
the  vertebral  column,  tearing  the  mesenteric  vessels.  Fracture  of  the 
skull  is  not  infrequently  attended  with  laceration  of  the  middle 
meningeal  artery  and  epidural  effusion  of  blood. 

Symptoms  of  subcutaneous  injury  of  blood  vessels  become  manifest 
when  important  vessels  are  torn  or  are  obstructed  by  thrombosis  after 
injury  to  their  walls.  Small  tears  or  defects  of  the  inner  wall  of  a 
blood  vessel  heal  without  giving  rise  to  symptoms,  though  in  a  certain 
number  of  cases  injuries  of  this  sort  are  followed  by  the  formation  of 
an  aneurism.  AVhcn  extensive  effusion  of  blood  in  the  region  of  a 
large  vessel  follows  soon  after  the  application  of  blunt  force,  suspicion 
of  injury  to  the  vessel  is  justified.  The  presence  of  a  harsh  systolic 
murmur  over  an  injured  area  indicates  the  rupture  of  a  large  artery 
(v.  Wahl").  This  sign  is  especially  valuable  in  connection  with  stah 
or  gunshot  wounds.  The  murmur  is  produced  by  an  increase  in  the 
lumen  of  the  artery,  due  to  a  gaping  wound  in  its  walls,  or  it  may  be 


584     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

due  to  the  passage  of  blood  over  a  thrombus  deposited  upon  the  intima 
of  an  injured  vessel.     Rotter*^  states  that  the  sign  is  present  only  when 
large  vessels  are  injured,  and  is  sometimes  absent.     When  an  injured 
limb  is  cold  and  cyanotic,  and  when  pulsation  fails  in  the  arteries 
peripheral  to  the  site  of  trauma,  the  diagnosis  of  complete  division  or 
obliteration  of  the  main  artery  may  be  regarded  as  certain.     This 
clinical  picture  often  follows  the  passage  of  a  wheel  over  an  extremity. 
In  cases  of  increasing  effusion  of  blood,  treatment  should  not  be 
delayed.     A  fatal  outcome  rapidly  follows  bleeding  into  the  abdominal 
and  cranial  cavities,  and  necrosis  soon  develops  as  the  result  of  large 
hematomata  in  the  extremities  which  —  by  pressure  —  interfere  with 
the  establishment  of  collateral  circulation.     Hematomata  sJiould  he 
widely  exposed,  the  clots  removed  with  sterile  gauze  wipes,  and  the 
'bleeding  vessel  or  vessels  deligated.     The  locating  of  the  divided  ves- 
sel may  be  facilitated  by  exsanguination  of  the  part  with  the  v. 
Esmarch  bandage  or  by  digital  or  tourniquet  pressure  upon  the  main 
trunk  of  the  blood  vessel.     In  this  way  it  is  feasible  to  deligate  the 
several  bleeding  vessels,  and  in  some  cases  it  is  possible  to  repair  (&?/ 
circular  or  lateral  suture)  vessels  which  are  essential  to  the  nourish- 
ment of  certain  parts,  such  as  the  common  femoral  and  the  common 
carotid  arteries   (Part  V,  chap.  v).     In  cases  in  which  the  divided 
vessels  are  not  essential  to  the  maintenance  of  nutrition,  ligature  of 
both  ends  suffices  the  purpose.    In  certain  cases,  ligature  of  the  main 
arterial  trunk,  at  a  distance  from  the  hematoma,  may  be  practiced. 

In  cases  of  thrombosis  of  large  vessels  of  the  extremities,  the  hema- 
toma should  be  opened  as  above  and  the  limb  elevated  with  the  view  of 
obviating  venous  stasis  and  subsequent  necrosis  of  tissue. 

Open  Injuries  to  Large  Vessels. —  Large  vessels  are  injured  in 
connection  with  insect  stabs,  gimshot,  contused  and  lacerated  wounds 
(explosions,  wounds  made  by  grenade  splinters,  bites  of  large  animals, 
avulsion  of  a  limb,  complicated  fractures  and  dislocations).  As  the 
veins  are  attached  to  the  fasciae,  they  are  more  likely  to  be  injured  by 
blunt  force  than  are  the  arteries  which,  being  more  resistant  and 
loosely  attached  to  the  soft  parts,  are  often  pushed  aside.  Blood 
vessels  are  also  injured  by  foreign  bodies  of  all  kinds,  such  as  pieces  of 
metal,  glass,  splinters  of  wood,  needles,  etc.  At  times  a  large  vessel 
is  injured  during  an  operation  by  a  knife,  scissors,  spoon,  sharp 
retractors,  etc.  Erosion  of  blood  vessels  results  from  prolonged  pres- 
sure by  fragments  of  broken  bones,  a  drainage  tube  or  a  tracheotomy 
cannula. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     585 

Injuries  of  blood  vessels  are  divided  into  those  involving  a  portion 
of  the  vessel  wall,  those  which  perforate  the  vessel,  and  those  which 
divide  the  vessel  entirely. 

Injuries  which  do  not  perforate  the  vessel  wall  usually  cicatrize, 
though  occasionally  severe  contusion  is  followed  by  the  formation  of  a 
true  aneurism. 

Perforating  wounds  of  blood  vessels  are  attended  with  severe  bleed- 
ing unless  produced  by  a  foreign  body  which  lessens  leakage,  or  in 
cases  of  small  perforating  wounds  (stab  or  gunshot  wound)  in  which 
rapid  coagulation  partially  closes  the  perforation,  or  when  a  con- 
tiguous muscle  covers  the  aperture  in  the  vessel.  Under  these  con- 
ditions, an  injured  vein  is  likely  to  be  obliterated  by  the  formation  of 
a  thrombus  and  the  flow  of  blood  from  an  aperture  in  an  artery  may 
form  a  false  aneurism.  When  the  wounds  in  an  artery  and  vein  are 
opposite  each  other,  an  arteriovenous  aneurism  develops.  Minute  per- 
forations of  arteries,  such  as  are  produced  by  a  needle,  may  heal 
spontaneously  without  giving  rise  to  symptoms. 

Complete  division  of  blood  vessels  presents  a  varying  picture.  Divi- 
sion of  blood  vessels  with  cutting  instruments  is  always  followed  by 
sharp  bleeding,  its  extent  depending  upon  the  size  of  the  vessel  divided. 
In  wounds  of  this  sort  arterial  bleeding  is  readily  differentiated  from 
venous. 

Arterial  hemorrhage  is  active,  light  red  in  color,  increases  in  force 
during  ventricular  systole  and  decreases  during  diastole.  Venous 
bleeding  is  dark  in  color  and  flows  slowly  and  steadil}'.  When  venous 
return  is  obstructed,  as  for  instance  in  pressure  from  tumors,  posture, 
etc.,  blood  flows  from  both  the  central  and  peripheral  ends  of  the 
divided  vein.  The  veins  leading  to  the  upper  thorax  are  intimately 
associated  with  the  surrounding  soft  parts  and  remain  open  after 
division,  consequently  blood  is  forcibly  projected  from  their  open 
mouths  during  expiration  (which  interferes  with  the  flow  of  blood  to 
the  heart)  and  is  drawn  into  the  vessel  during  inspiration.  In  this 
way  air  may  be  aspirated  info  the  veins  and  gain  access  to  the  heart, 
giving  rise  to  fatal  air  embolism. 

In  cases  of  punctured  wounds  with  restricted  ports  of  egress,  the 
destructive  features  of  arterial  and  venous  bleeding  are  not  present. 

Transverse  division  of  blood  vessels  due  to  blunt  force,  occurring  in 
connection  with  contusions  and  lacerations,  differs  from  injuries 
inflicted  by  cutting  instruments.  Wlicn  blood  vessels  are  crushed  the 
intima  and  m.edia  curl  inward  and  either  close  the  lumen  or  produce 


586     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

conditions  favorable  to  the  formation  of  a  thrombus.  Thus  bleeding 
may  be  entirely  absent  in  cases  of  complete  avulsion  of  a  limb  in  which 
the  main  vessels  are  torn  across.  The  mechanism  of  this  phenomenon 
is  as  follows:  The  intima  is  stretched  and  tears  at  the  limit  of  its 
elasticity;  the  media  tears  at  a  point  peripheral  to  where  the  intima 
gives  way  and  curls  into  the  lumen ;  the  adventitia  is  elongated  to  the 
diameter  of  a  thin  thread  before  it  separates.  If  the  destructive  force 
is  applied  in  a  rotary  fashion,  so  that  the  vessel  is  twisted,  occlusion 
of  the  lumen  is  complete. 

The  dangers  of  open  injuries  of  blood  vessels,  besides  those  attend- 
ant upon  loss  of  blood,  are  secondary  hemorrhage  and  air  embolism. 

Secondary  hemorrhage  is  very  likely  to  follow  spontaneous  arrest 
of  bleeding,  especially  in  cases  of  stab  wound  when  an  instrument 
seals  an  opening  in  a  vessel  and  is  then  withdrawn.  It  happens  when 
an  occluding  thrombus,  following  the  application  of  blunt  force^  is 
dislodged  by  movements  of  the  part  or  by  a  suppurative  process,  and 
it  also  occurs  when  the  fragment  of  a  broken  bone  has  made  pressure 
on  a  blood  vessel  for  some  time,  which  then  becomes  necrotic. 

The  entrance  of  air  into  an  injured  internal  jugular  or  subclavian 
vein  during  inspiration  may  lead  to  so-called -air  embolism.  In  severe 
cases  death  occurs  at  once  or  in  a  few  hours.  Fatal  outcome  is  pre- 
ceded by  restlessness,  apprehension,  severe  dyspnea,  cyanosis,  flutter- 
ing pulse,  unconsciousness  and  convulsions.  The  symptoms  are  due  to 
interference  with  the  cardiac  and  respiratory  functions  and  to  cerebral 
anemia.  The  aspirated  air  enters  the  right  ventricle,  from  which  it  is 
propelled  into  the  lungs  where  it  interrupts  the  circulation,  thus  pre- 
venting sufficient  blood  from  reaching  the  left  ventricle,  and  acute 
anemia  of  the  cerebral  centers  results.  In  a  certain  number  of  cases 
overdistention  of  the  right  heart  may  be  responsible  for  death. 
According  to  Senn,^^  the  fatal  outcome  is  ascribable  to  interruption 
of  the  circulation  in  the  lung. 

Air  embolism  of  moderate  degree  may  be  observed  during  operations. 
When  a  small  quantity  of  air  gains  access  to  an  injured  vein  and  the 
puncture  is  immediately  closed  by  pressure  no  discernible  disturbances 
may  follow.  However,  as  an  accurate  estimate  in  this  connection  is 
not  possible,  an  effort  should  be  made  to  expel  the  aspirated  air. 
For  this  purpose  the  thorax  should  be  compressed  during  expiration 
and  at  the  same  time  the  compressing  agent  should  be  lifted  from  the 
perforation  in  the  vein ;  this  agent  should  be  reapplied  during  inspira- 
tion.    The  entrance  of  additional   air  is  obviated  by  flooding  the 


I 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     587 

operative  field  with  physiological  salt  solution.  When  the  danger  is 
over  the  vein  is  grasped  with  forceps  and  deligatcd  in  the  usual  man- 
ner.    In  severe  cases  aspiration  of  the  right  ventricle  is  justifiahle. 

The  recognition  of  open  injuries  of  blood  vessels  is  not  attended 
with  difficulty  unless  the  characteristic  free  flow  of  blood  is  interfered 
with.  Injuries  that  do  not  penetrate  the  lumen  of  vessels  escape 
notice  unless  the  wound  is  large ;  inspection  reveals  the  true  condition 
of  affairs.  In  stah  and  gunshot  wounds  the  small  size  of  the  wound 
may  prevent  the  exit  of  blood  in  sufficient  quantity  to  arouse  suspicion. 
In  cases  of  this  sort,  large  hematomata  are  formed  which  give  rise  to 
serious  complications.  This  is  especially  liable  to  happen  when  large 
blood  vessels  located  beneath  fascia  are  punctured  or  severed.  The 
location  of  the  wound  and  the  gradual  appearance  of  a  "doughy" 
swelling  and  the  presence  of  a  systolic  friction  murmur  should  make 
the  diagnosis. 

When  a  large  hematoma  is  located  in  a  vascular  region  it  is  not 
always  possible  to  be  certain  as  to  the  character  of  injury  to  the  vessel. 
When  the  peripheral  arterial  pulse  is  absent,  complete  division  of  the 
artery  may  be  assumed.  When  the  distal  pulse  is  present  but  is 
weaker  than  on  the  corresponding  opposite  side  of  the  body,  and  when 
a  systolic  hruit  is  present  over  the  seat  of  injury  and  is  conveyed 
toward  the  periphery,  the  side  of  the  artery  is  probably  punctured; 
when  there  is  a  simultaneous  perforation  of  a  contiguous  artery  and 
vein  and  these  communicate  with  each  other  {arteriovenous  aneurism) , 
the  bruit  is  conveyed  in  both  directions. 

The  treat me7it  consists  of  temporary  and  permanent  arrest  of  hem- 
orrhage (p.  32)  for  the  purpose  of  checking  the  loss  of  blood.  This 
is  followed  by  the  usual  cleansing  of  the  wound  and  tissues  contiguous 
to  it.  The  permanent  arrest  of  bleeding  is  accomplished  by  either 
ligating  or  suturing  the  vessel.  Wlien  there  is  no  surface  bleeding, 
the  site  of  injury  should  be  exposed  and  the  hematoma  removed. 
Primary  repair  of  injured  blood  vessels  is  more  likely  to  be  successful 
than  when  the  formation  of  an  aneurism  is  awaited.  In  cases  of  small 
hematomata  following  stab  or  gunshot  wounds,  interference  may  be 
postponed  as  spontaneous  healing  frequently  follows. 

The  ligature  or  suture  of  large  vessels  should  be  supplemented  by 
immobilization  of  the  injured  part  for  from  two  to  three  weeks. 

In  cases  of  severe  bleeding  the  proper  execution  of  immediate  hemo- 
stasis  is  a  life  saving  measure,  and  is  most  effectually  carried  out  in 
connection  with  injuries  of  the  extremities.     For  the  purpose,  the 


588     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

central  portion  of  the  limb  may  be  constricted  by  means  of  the  hands 
or  a  temporary  tourniquet  (p.  34)  or  the  main  artery  may  be 
compressed  with  the  fingers. 

When  constriction  of  the  part  is  impracticable,  central  pressm'e  on 
the  main  artery  is  a  most  useful  measure.  When  the  pressure  is 
firmly  applied  the  venous  circulation  is  also  arrested.  When,  how- 
ever, the  vein,  which  is  very  easily  compressed,  is  obstructed  and  the 
artery  is  only  partially  shut  oif  by  the  pressure,  bleeding  is  increased. 
For  the  purpose  pressure  is  made  with  the  second  and  third  fingers  of 
the  left  hand  reinforced  by  the  superimposed  thumb.  In  this  way 
the  common  femoral  may  be  compressed  against  the  pubes ;  the  sub- 
clavian against  the  first  rib  (behind  the  clavicle)  ;  the  common  carotid 
against  the  transverse  processes  of  the  vertebrae;  and  the  abdominal 
aorta  may  be  forced  against  the  bodies  of  the  lumbar  vertebrae  with 
the  closed  fist. 

In  place  of  digital  compression  the  femoral  may  be  obstructed  by 
hyperextension  of  the  thigh ;  and  pressure  made  upon  the  subclavian 
by  carrying  the  arm  sharply  across  the  back.  However,  neither  of 
these  measures  acts  with  as  much  certainty  as  the  manual  pressure 
described  above. 

When  bleeding  occurs  from  vessels  so  situated  that  central  com- 
pression is  impracticable,  the  employment  of  direct  pressure  in  the 
wound  with  the  finger  is  justified  despite  the  involved  danger  of  infec- 
tion. This  means  of  hemostasis  may  be  used  to  control  bleeding  from 
the  innominate  vessels  until  permanent  measures  of  relief  become 
available. 

Permanent  arrest  of  hleeding  is  accomplished  by  ligature  or  by 
repair  of  the  injured  vessel  by  suture. 

The  ligature  may  be  used  on  vessels,  the  obliteration  of  which  does 
not  interfere  with  nutrition  of  the  part.  The  injured  limb  should  be 
exsanguinated  with  the  v.  Esmarch  bandage  and  the  vessels  exposed. 
When  the  vessels  are  divided  the  ends  are  grasped  with  forcipressure 
and  deligatcd.  When  the  side  of  the  vessel  is  perforated,  the  injured 
portion  is  dissected  free  and  a  ligature  is  passed  above  and  below  by 
means  of  a  ligature  carrier,  and  after  the  ligatures  are  tied  the 
traumatized  portion  of  the  vessel  is  excised. 

In  cases  in  which  circulatory  exclusion  of  the  part  supplied  b}'  the 
injured  vessels,  especially  when  both  the  artery  and  vein  are  injured, 
is  likely  to  lead  to  serious  nutritive  changes,  an  effort  at  repair  should 
he  made.     This  is  illustrated  in  connection  with  ligature  of  the  com- 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     589 

moil  carotid,  M'liich  is  followed  hy  cerebral  softening  and  by  the 
development  of  necrosis  "wliicli  at  times  follows  exclusion  of  the  sub- 
clavian, the  axillary',  the  femoral,  and  the  popliteal  arteries,  especially 
when  the  causative  trauma  is  attended  with  much  bloody  infiltration 
of  the  soft  parts  or  occurs  in  cases  of  arterial  disease.  Even  though 
repair  of  the  vessel  is  ultimately  followed  by  occluding  thrombosis,  the 
temporary  reestablishment  of  the  circulation  creates  conditions  more 
favorable  to  the  satisfactory  establishment  of  collateral  circulation 
than  obtains  when  the  vessel  is  immediately  deligated. 

The  suture  of  tlood  vessels  is  either  lateral  or  end  to  end  (circular). 
Repair  of  a  lateral  perforation  was  first  carried  out  in  the  human  by 
Shede**  (1882)  after  H.  Braun*^  had  shown  experimentally  that 
thrombosis  did  not  always  follow  the  procedure. 

The  feasihility  of  circular  suture  of  vessels  was  experimentally 
demonstrated  by  Gluck"  (1882)  and  by  von  Jassinowsky"  (1889). 
The  latter  showed  that,  despite  the  technical  difficulties  presented, 
union  of  vessels  could  be  accomplished  without  the  occurrence  of  sec- 
ondary bleeding,  the  formation  of  aneurism,  or  the  development  of 
thrombosis  (Jacobstahl*^).  The  first  successful  circular  repair  of  a 
vessel  in  the  human  was  done  by  jMurphy*^  (1897)  who  reunited  a 
common  femoral  artery  by  invagination. 

During  the  repair  the  vessel  is  temporarily  occluded  ahove  and 
heloiv  the  site  of  injury  with  a  lightly  applied  clamp,  the  blades  of 
which  are  covered  with  rubber  to  prevent  trauma  to  the  endothelium 
and  subsequent  trombus  formation.  The  Crile^*'  clamp  or  Hopf- 
nerV^  intestinal  forceps  serve  the  purpose  very  well,  though  digital 
compression  may  be  used  with  advantage.  Fine  silk  covered  with 
vaseline  is  the  suture  material  of  choice.  Eden^^  uses  horsehair  that 
has  been  boiled  for  ten  minutes  and  presers'ed  in  sterile  glycerin. 

The  closure  of  longitudinal,  oblique,  and  incomplete  transverse  in- 
juries of  blood  vessels  may  be  accomplished  by  lateral  suture.  For 
the  purpose  a  fine,  round  (not  a  cutting)  needle,  armed  with  fine 
silk,  is  used.  The  entire  thickness  of  the  vessel  wall  is  perforated  and 
the  closure  is  made  with  a  continuous  suture.  The  suture  should 
bring  the  endothelial  coats  of  the  vessels,  from  which  proliferation, 
and  coadhesion  takes  place,  in  close  apposition.  AVhen  repairing  ar- 
teries a  second  layer  of  sutures  may  be  introduced  into  the  adventitia 
and  perivascular  tissue  with  the  view  of  reenforcing  the  first.  After 
the  repair  is  accomplished  the  clamps  are  gradually  loosened  so  that 


590     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


the  coapted  suture  line  may  become  adherent  before  the  point  of 
repair  is  subjected  to  the  full  pressure  of  the  blood  (Jassinowsky*^). 
Circular  suture  of  completely  divided  vessels  is  best  carried  out  by 
the  methods  of  Carrel-'^  and  Stich.^*  The  two  ends  of  the  vessel  are 
approximated  by  means  of  three  stay  sutures  which  are  tied  and  left 
long  for  the  purpose  of  making  possible  the  introduction  of  the  con- 
tinuous suture  which  brings  the  ends  of  the  vessel  together.  The 
suture  passes  through  all  the  coats  of  the  vessel  and  brings  the  intima 
of  the  divided  ends  in  contact  with  each  other  as  shown  in  Fig.  195. 


Fig.  195. —  Circulae  Suture  of  a  Blood  Vessel    (Carrel). 

This  method  may  also  be  used  in  uniting  smaller  vessels  (in  trans- 
planting organs  such  as  the  thyroid  gland,  etc.).  The  cannula  method 
of  arterial  anastomosis  which  presents  less  technical  difficulties  is 
based  on  the  work  of  Queirvolo,^^  who  attempted  to  repair  the  portal 
vein.  Later  Payr^^  used  a  tubule  consisting  of  absorbable  magnesium 
for  the  purpose.  The  cannula  must  correspond  in  size  to  the  divided 
vessel.  Crile  and  Hutchins^°  have  modified  the  technic  of  the  proced- 
ure as  shown  in  Fig.  22,  which  when  studied  in  connection  with  the 
legend  is  self  explanatory.  The  fundamental  principle  of  the  method 
lies  in  the  apposition  of  intima  to  intima.  Firm  union  occurs  in  ten 
days.    The  cannula  is  slowly  absorbed.  When  the  ends  of  a  Mood  vessel 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     591 

are  widely  separated,  an  effort  to  reestablish  the  circulation  by  free 
transplantation  of  a  portion  of  a  vein  (saphenous  vein)  and  circular 
suture  may  be  made  (Lexer^'). 

Healing  of  wounds  of  arteries  and  veins,  after  ligature  or  suture, 
is  preceded  by  cohesion  of  the  apposed  surfaces  by  means  of  a  blood 
plate  thrombus  and  the  deposit  of  a  thin  layer  of  fibrin ;  occluding 
thrombosis  occurs  only  when  infection  develops.  At  the  end  of  a  few 
days  the  site  of  repair  is  covered  with  proliferated  endothelium.  This 
is  followed  by  the  production  of  connective  tissue  which  is  derived 
from  the  media  and  the  adventitia.  Elastic  fibers  are  sparingly  pro- 
duced in  the  outer  layers  of  the  vessel  but  are  found  in  considerable 
quantity  in  the  intima  (Jacobstahl**).  The  fibrinous  deposit  in  the 
wound  area  ultimately  becomes  organized   (Marchand^*). 

Injuries  of  Lymphatic  Vessels. — Injury  of  the  thoracic  duct  or  one 
of  its  branches  possesses  surgical  importance.  The  duct  may  be 
injured  where  it  enters  the  junction  of  the  internal  jugular  and  the 
subclavian  veins  on  the  left  side  of  the  neck  during  operations,  or  as 
the  result  of  stab  or  gunshot  woimds.  Prolonged  discharge  of  chyle 
in  large  quantities  may  cause  disturbances  in  nutrition,  though  the  flow 
ultimately  ceases.  If  the  stumps  of  the  divided  duct  are  found  they 
may  be  deligated ;  failing  in  this,  tamponade  usually  accomplishes  the 
same  purpose.  Reestablishment  of  lymphatic  circulation  occurs  as 
the  result  of  lateral  anastomosis.  WendeP*  states  that  the  duct  fre- 
quently opens  into  several  places  in  the  large  veins  and  these  take  up 
the  function  of  the  injured  one. 

Severe  contusions  of  the  thorax  and  injuries  of  the  vertebral  col- 
umn may  involve  the  duct  in  its  thoracic  portion.  Trauma  of  suffi- 
cient force  to  injure  the  duct  in  this  situation  usually  results  fatally 
from  other  causes.  When  this  is  survived,  solution  of  continuity  of 
the  duct  is  followed  by  the  extravasation  of  ch3'le  into  the  pleural  sac. 
Chylothorax  at  times  follows  obstruction  of  the  duct,  due  to  pressure 
from  carcinomatous  or  tuberculous  lymphadenitis. 

A  similar  condition  of  affairs  occurs  in  the  abdominal  cavity  {Chy- 
lous ascites). 

The  diagnosis  is  made  by  recognizing  the  character  of  the  aspirated 
fluid. 

Traumatic  extravasation  of  chyle  in  the  thorax  and  abdomen  usu- 
ally make  sufficient  pressure  upon  the  site  of  the  injured  duct  to  cause 
spontaneous  repair.  When  a  pleural  effusion  causes  dyspnea,  only  a 
portion  of  the  fluid  should  be  slowly  withdrawn  as  the  suction  of  the 


592     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

aspiration  has  a  tendency  to  keep  the  wound  in  the  duct  open  and 
favors  reaccumulation  of  the  fluid. 

Lymph  vessels  are  divided  in  all  wounds  and  subcutaneous  injuries. 
However,  the  collateral  circulation  of  this  system  is  so  extensive  that 
they  escape  notice.  At  times,  temporary  lymphorrhea  attracts  atten- 
tion, especially  after  the  removal  of  a  large  number  of  glands.  On 
the  other  hand,  extravasation  of  lymph  often  follows  severe  subcu- 
taneous injuries.  As  a  rule,  the  lymph  mingles  with  the  blood,  al- 
though in  some  instances  of  loosening  of  the  skin  (decollement),  a 
characteristic  clinical  picture  is  presented  (p.  559). 

Lyniphectasia  of  the  skin  occurs  in  connection  with  chronic  ob- 
struction of  return  circulation,  especially  in  the  extremities.  When 
the  dilated  lymphatic  vessels  rupture,  a  lymph  fistula  may  be  es- 
tablished. 

Injuries  of  Joints. — Subcutaneous  Injuries. — Subcutaneous  in- 
juries of  joints  are  divided  into  contusions,  sprains,  and  dislocations. 

Contusions  are  caused  by  the  application  of  direct  blunt  force  (blow, 
fall,  etc.),  or  by  indirect  force,  such  as  a  fall  upon  the  feet  which 
results  in  injury  to  the  knee,  or  a  blow  on  the  trochanter  which  pro- 
duces a  contusion  in  the  hip  joint,  etc. 

Direct  injuries  of  joints  are  not  limited  to  trauma  to  the  synovia 
but  are  often  complicated  by  contusions  of  the  contiguous  soft  parts, 
avulsion  of  portions  of  hone  or  cartilage,  separation  of  the  entire 
articular  cartilage  or  fractures  extending  into  the  joint.  Indirect 
injuries  are  often  attended  with  crushing  of  the  epiphyseal  spongiosa 
and  the  formation  of  an  interosseous  hematoma. 

The  dominant  symptom  of  joint  injuries  is  the  effusion  of  blood 
into  the  synovial  sac,  i.  e.,  hemartJirosis.  The  distended  capsule  ob- 
literates the  normal  contour  of  the  joint,  the  outlines  of  the  synovial 
sac  being  clearly  outlined,  unless  swelling  of  the  soft  parts  conceal  this 
sign.  Hemarthrosis  develops  rapidly,  reaching  its  maximum  of  disten- 
tion in  about  twenty-four  hours.  Movements  of  the  joints  are  exceed- 
ingly painful. 

In  uncomplicated  cases,  and  in  those  attended  with  moderate  ef- 
fusion of  blood,  the  prognosis  is  favorable,  complete  resumption  of 
function  being  the  rule. 

More  or  less  loss  of  function  follows  when  there  is  delay  in  absorp- 
tion of  the  hemarthrosis.  The  effusion  is  most  readily  taken  up  when 
a  tear  in  the  joint  capsule  allows  the  blood  to  infiltrate  the  surrounding 
soft  parts,  from  which  it  is  more  readily  absorbed.     When  the  coagu- 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     593 

lum  coats  the  synovia,  absorption  is  very  slow  as  the  lymphatics  of 
joints  do  not  communicate  directly  with  those  of  the  general  system. 
However,  the  admixture  of  synovial  fluid  and  fat  to  the  effused  blood 
interferes  with  complete  coagulation  (Jaffe^"). 

Coagulated  hloocl  in  joints  is  very  gradually  absorbed,  but  in  a 
certain  number  of  cases  causes  irritation  which  in  turn  provokes  a 
serous  inflammation;  this  may  ultimately  cause  the  development  of 
obstinate  recurring  hydrops  articuli.  In  some  cases  in  which  the 
joint  is  held  quiescent  for  a  long  time,  the  clot  becomes  organized  and 
anliijlosis  of  the  joint  results.  Large  effusions  cause  permanent  disten- 
tion of  the  capsule  and  the  formation  of  a  flail  joint.  Rare  sequelae 
are  subcutaneous  suppuration  and  the  development  of  joint  tubercu- 
losis. The  latter  is  explained  on  the  ground  that  hematogenous  infec- 
tion finds  conditions  favorable  to  its  development,  or  that  injury 
liberates  into  the  joint  dormant  infection  resident  in  the  contiguous 
bone.  Pyogenic  infection  may  gain  access  to  a  hemarthrosis  through 
a  small  superficial  wound  received  at  the  time  the  primary  injury  was 
inflicted. 

The  recognition  of  simple  contusion  of  a  joint  is  based  on  the  char- 
acter of  the  causative  trauma  and  the  clinical  findings.  The  presence 
of  a  distended  capsule,  of  fluctuaiion,  and  the  occurrence  of  "snow- 
ball" crepitation  when  the  effusion  is  manipulated,  together  with  evi- 
dence of  a  superficial  contusion,  are  indicative  of  hemarthrosis.  Severe 
pain  upon  pressure  of  certain  areas  and  unnatural  lateral  motility  of 
the  joint  indicate  rupture  of  ligaments.  Fractures  usually  cause  char- 
acteristic deformities.  Fissured  fractures  and  crushing  of  the  epi- 
physes can  be  recognized  only  by  X-ray. 

The  treatment  should  be  directed  toward  removal  of  the  effusion. 
The  limb  should  be  immobilized  in  gypsum,  so  applied  that  equable, 
moderate  pressure  is  made,  beginning  at  the  periphery  and  extending 
well  bej'ond  the  injured  joint.  In  this  way  pain  is  relieved,  the 
effusion  of  blood  is  lessened,  and  absorption  is  promoted.  The  appli- 
cation of  cold  and  immediate  massage  is  contraindicated.  In  the 
absence  of  a  fracture,  immobilization  is  not  maintained  for  more  tJxan 
a  iceeJi;  at  the  end  of  this  time,  massage  and  active  and  passive  motion 
and  ivarm  baths  may  be  employed  with  the  view  of  preventing  im- 
pairment of  function.  In  eases  of  large  hemarthrosis,  aspiration  of 
the  joint  is  a  useful  measure,  and  is  followed  by  immobilization,  etc., 
as  stated. 

'Winems^°  recrards  immobilization  in  this  class  of  cases  as  unneces- 


594     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

sary.  He  believes  that  immediate  active  motion  obviates  ultimate 
impairment  of  function.  His  work  would  seem  to  support  the  ra- 
tionale of  the  method  in  certain  cases.  Further  observation,  especially 
in  cases  with  large  effusion  of  blood,  is  necessary  before  the  measure 
will  be  universally  employed. 

The  term  sprain  is  applied  to  the  stretching  and  tearing  of  the 
capsule  and  ligaments  of  a  joint  by  carrying  the  range  of  its  motion 
beyond  the  normal  (hyperextension  or  hyperflexion  or  the  rotation  of 
a  hinge  joint). 

The  causation  of  a  sprain  varies  with  the  character  of  joint  injured. 
The  ankle  joint  is  often  sprained  by  lateral  overstrain  when  the  medio- 
tarsal  reaches  its  limit  of  motility;  the  wrist  by  a  fall  upon  the  ex- 
tended or  flexed  hand ;  the  knee  by  abduction  or  rotation  of  the  leg. 

Rupture  of  the  capsule  or  of  ligaments  occurs  at  the  point  where 
the  stretching  force  reaches  its  maximum.  The  tear  in  a  ligament 
may  be  slight  or  extensive  in  degree.  Strong,  heavy  ligaments  are 
likely  to  avulse  small  portions  of  bone  at  the  site  of  their  attachment 
(Pott's  fracture).  In  some  instances  an  entire  process,  such  as  the 
olecranon,  is  torn  off.  In  situations  in  which  the  motion  of  a  joint 
is  limited  by  a  tendon  or  a  muscle,  these  may  be  partially  or  com- 
pletely torn,  and  in  another  class  of  cases  portions  of  the  fibro-articular 
cartilage  are  torn  off  (floating  cartilage)  or  tendons  and  muscles  may 
be  caught  between  joint  surfaces. 

The  symptoms  of  a  sprain  begin  with  pain  which,  in  cases  of  injury 
of  the  capsule  or  ligaments,  ceases  when  the  joint  is  immobilized,  but 
may  disappear  spontaneously  when  these  parts  are  simply  stretched. 
In  a  few  hours  the  joint  swells  so  that  its  normal  landmarks  are  oblit- 
erated. Ecch^'mosis  makes  its  appearance  over  the  site  of  torn  liga- 
ments or  where  an  avulsion  fracture  has  occurred.  As  motion  is  usu- 
ally very  painful,  there  is  loss  of  function  commensurate  with  the 
extent  of  the  injury. 

The  course  and  sequelae  of  sprains  are  the  same  as  with  contusions. 
Simple  sprains  unattended  with  rupture  of  ligaments  or  injury  to  the 
bone  are  followed  by  complete  return  to  the  normal.  Persistent  pain 
and  permanent  loss  of  function  occur  in  cases  of  avulsion  of  portions 
of  articular  cartilage  and  when  a  portion  of  torn  capsule  is  "pinched" 
between  the  joint  surfaces.  Neglected  fractures  lead  to  malformations 
and  loss  of  function ;  and  the  rupture  of  important  ligaments  is  fol- 
lowed by  abnormal  motility  of  the  joint,  especially  when  motion  is 
begun  too  early.    Incomplete  repair  predisposes  to  additional  injury. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     595 

An  exact  diagnosis  is  not  always  easy.  The  character  of  the  trauma 
and  the  degree  and  location  of  the  swelling  are  helpful  guides.  The 
somewhat  indefinite  diagnosis  of  sprain  covers  a  wide  field ;  however, 
recognition  of  the  exact  conditions  are  essential  to  intelligent  treat- 
ment. Localized  tenderness  indicates  the  existence  of  a  torn  ligament. 
In  the  ankle  joint  a  tender  point  is  found  over  the  deltoid  ligament 
and  in  the  knee  the  tenderness  may  be  elicited  at  the  edge  of  the  ar- 
ticular surfaces.  Even  small  collections  of  blood  may  be  felt  by  com- 
paring the  injured  with  the  opposite  normal  joint. 

Fractures  that  occur  in  connection  with  sprains  usually  present  a 
typical  picture  such  as  is  seen  in  Pott's  fracture,  fracture  of  the 
patella,  separation  of  the  lower  epiphysis  of  the  radius,  etc. ;  however, 
avulsion  fractures,  especially  when  associated  with  large  hematomata, 
are  likely  to  escape  detection.  Rontgenography  reveals  the  presence 
of  the  latter  conditions  in  a  large  number  of  cases  in  which  their  pres- 
ence is  not  suspected.  Palpation  and  the  careful  testing  of  function 
reveals  the  existence  of  injury  to  muscles  and  tendons. 

The  treatment  is  similar  to  that  employed  in  cases  of  contusion. 
When  there  is  moderate  extravasation  of  blood  and  slight  disturbance 
of  function,  the  immediate  emplo^Tuent  of  massage  is  permissible.  In 
the  other  classes  of  cases,  immobilization  should  he  maintained  for  one 
week,  except  in  fractures  when  the  joint  should  be  held  still  for  three 
weeks.  In  the  latter  instance,  molded  splints  should  be  used,  which, 
permit  of  temporary  removal  for  the  purpose  of  massage  which  is 
begun  at  the  end  of  a  week  following  the  injury. 

Persistence  of  disturbances  indicates  incarceration  of  the  joint  cap- 
sule, avulsion  of  portions  of  articular  cartilage  or  extensive  rupture  of 
important  ligaments.  Cases  of  this  sort  demand  operative  exposure 
and  repair  of  the  injury. 

A  certain  number  of  cases  of  joint  injuries  are  attended  with 
subchondral  effusion  of  hlooel  and  avulsions  of  small  portions  of  artic- 
ular cartilage.  The  latter  occurs  most  often  in  the  knee  and  in  the 
elbow  joints,  a  segment  of  cartilage  being  ''pulled  off"  with  the 
ligament. 

Floating  cartilages,  or  "joint  mice,''  may  be  several  centimeters  in 
diameter,  and  are  either  partially  or  fully  detached  from  the  articular 
cartilage.  It  is  probable  that  the  separation  of  segments  of  articular 
cartilage  occurs  slowly,  the  growth  of  granulation  tissue  completing 
the  partial  loosening  attendant  upon  trauma  which  is  followed  by  the 
localized  infiltration  of  blood  and  some  necrosis  (Koenig"). 


506     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  primary  clinical  picture  is  that  of  a  joint  injury.  At  the  €nd 
of  a  varyingly  protracted  period  of  time  (which  may  be  days  or 
mouths  or  years  (Yollbrecht*'^),  the  traumatized  segment  of  cartilage 
is  completely  loosened  and  symptoms  of  joint  locking  and  synovitis 
appear.  These  symptoms  do  not  differ  from  those  associated  with  so- 
called  pathological  joint  mice,  except  that  the  latter  appear  less  often. 
The  sudden  incarceration  of  the  "mouse"  between  the  articular  sur- 
faces of  the  joint  is  attended  with  severe  pain  and  immediate  locking 
of  the  joi7it,  which  disappear  when  appropriate  manipulations  force 
the  loose  body  into  a  harmless  situation.  This  is  usually  accomplished 
by  the  patient  himself.  In  addition  to  this,  the  joint  is  kept  in  a  state 
of  chronic  irritation  which  is  expressed  by  thickening  of  the  capsule 
and  frequent  attacks  of  serous  effusion  (hydrarthrosis) . 

The  ultimate  fate  of  traumatic  floating  cartilages  varies.  Some  are 
absorbed  while  others  remain  intact  but  undergo  certain  histological 
changes  (Schmieden*^^).  When  absorption  takes  place  the  loose  body 
becomes  embedded  in  the  synovia  and  is  gradually  dissolved  as  the  re- 
sult of  connective  tissue  proliferation ;  however,  complete  absorption 
does  not  always  occur.  In  some  instances,  the  bony  surface  of  the 
cartilage  becomes  smooth  and  later  the  body  is  encased  in  connective 
tissue  and  remains  attached  to  the  synovia  by  a  fibrous  pedicle. 
Trauma  may  tear  the  pedicle  and  the  body  again  become  a  free,  dis- 
turbing element  in  the  joint.  In  other  instances,  the  loose  cartilage 
remains  intact  and  connected  with  the  surface  of  the  joint.  Joint  bodies, 
of  long  standing  often  become  calcified.  All  loose  cartilages  undergo 
changes  in  form.  At  first,  the  rough  area  avulsed  from  the  spongiosa 
and  the  concave  articular  surface  are  easily  identified ;  as  time  goes 
on  these  are  obliterated  by  irregular  cartilaginous  deposits  so  that 
traumatic  bodies  can  no  longer  be  distinguished  from  the  so-called 
pathological  ones.  Even  the  identification  of  normal  cartilage  in  the 
center  of  the  calcareous  bodies  does  not  necessarily  establish  a  trau- 
matic origin,  as  Koenig*'^  has  shown  that  spontaneous  separation  of 
segments  of  articular  cartilage  occurs  in  osteochondritis  dissecans. 

BIBLIOGRAPHY 

1.  Morell-Lavallee.    No.  2. 

2.  KoHLER.    Deutsch.  Zeitschr.  f.  Chir.  Bd.  29,  1889. 

3.  FiEBiGER.     Wien  Klin.  Woch.,  1897. 

4.  Hammer.     Beitr.  z.  klin.  Chir.,  1899. 

5.  Sauerbruch.     Chir.  kong.  Verb.,  1908,  i. 

6.  V.  Bramank.     Chir.  kong.  Verb.,  1893,  i. 


MECHANICAL  INJURIES  OF  DIFFERENT  TISSUES     597 

7.  KoNiG.    Chir.  kong.  Verb.,  1908,  i. 

8.  Lexer  aud  Baus.    Miinch.  med.  Woeli.,  1910. 

9.  Friedrich.     Handb.  d.  piakt.  Chir.  Bd.  5,  Aufl.  3. 

10.  Schlatter.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  91,  1908. 

11.  Schurmayer.    Zentrbl.  f.  Chir.,  1897. 

12.  Krukenberg.     Lehrb.  d.  mech.  Heilkunde,  Stuttgart,  1896. 

13.  Malewitch.     Basel,  1908. 

14.  KiMURA.     Miinch.  med.   Woch.,  1912;   also  Deutsch.   Zeitschr.  f.   Chir. 

Bd.  115,  1912. 

15.  Lotheisen.     Arch.  f.  klin.  Chir.  Bd.  64,  1901. 

16.  Marchand.     Deutsch.  Chir.,  1901. 

17.  Laxge.     Miiuch.  med.  Woch.,  1902;  also  Zeitschr.  f.  Orthopad.  Bd.  17, 

1906. 

18.  NicOLADOKi.     Arch.  f.  klin.  Chir.  Bd.  27,  1882. 

19.  Drobruk.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  43,  1896. 

20.  VuLPius.    Samml.  klin.  Votr.  No.  197,  1897. 

21.  HOFFA.     Lehrb.  d.  orth.  Chir.,  Stuttgart,  1906. 

22.  Sciiede.     Handb.  d.  spez.  Therap.,  etc.,  of  Penzoldt  and  Stintzing,  1898, 

with  lit. 

23.  MOMBURG.     Arch.  f.  klin.  Chir.  Bd.  70,  1903. 

24.  Marchaxd.     Deutsch.  Chir.,  1901. 

25.  Ingebrigtsen.    Miinch.  med.  Woch.,  1913. 

26.  Margulies.     Virchow's  Arch.  Bd.  191,  1908. 

27.  Ramsauer.     Bonn,  1907. 

28.  Kolliker.     Deutsch.  Chir.,  1890,  with  lit. 

29.  Payr.     Chir.  Kong.  Verh.,  1900,  ii. 

30.  Forametti.     Arch.  klin.  Chir.  Bd.  73,  1904. 

31.  V.  Bruxs.     See  Gleiss  No.  32. 

32.  Gleiss.     Beitr.  z.  klin.  Chir.  Bd.  10,  1893. 

33.  TiLLMAXXS.     Arch.  f.  klin.  Chir.  Bd.  27,  1882,  with  lit. 

34.  Letievaxt.     See  Korte  No.  38. 

35.  Hackexbruch.     Chir.  kong.  Verh.,  1903,  ii. 

36.  Cushixg.     Anns,  of  Surg.,  1903. 

37.  Ballaxce  and  Stewart.     Brit.  ^Med.  Jr.,  1903. 

38.  Korte.    Deutsch.  med.  Woch.,  1903. 

39.  Frazier.     Univ.  of  Penn.  Med.  Bull.,  1903. 

40.  Etzold.     Beitr.  z.  klin.  Chir.  Bd.  29,  1889. 

41.  V.  Wahl.     Samml.  klin.  Vortr.,  1885,  No.  258. 

42.  Rotter.     Samml.  klin.  Votr.,  1893,  No.  72. 

43.  Sexx.     Anns,  of  Surg.,  1885. 

44.  Shedb.     See  Jacobstahl,  No.  48. 

45.  H.  Braun.     See  Jacobstahl,  No.  48. 

46.  Gluck.     See  Jacobstahl,  No.  48. 

47.  Jassixowsky.     See  Jacobstahl,  No.  48. 

48.  Jacobstahl.     Samml.  klin.  Vortr.,  1905,  No.  396,  with  lit. 

49.  Murphy.     Med.  Record,  N.  Y.,  1897. 

50.  Crile.     Hemorrhage  and  Transfusion,  Appleton,  N.  Y.,  1909. 

51.  Hopfxer.     Verh.  d.  path.  Gesell.,  1904. 

52.  Edex.     Beitr.  z.  klin.  Chir.  Bd.  80,  1912. 

53.  Carrel.     Bull.  Johns  Hopkins  Hosp.,  1907. 

54.  Stick.     Beitr.  z.  klin.  Chir.  Bd.  53,  1907. 

55.  Oueirvolo.     Moleschott.  Untersuch..  1895,  xv. 

56.  Payr.     Arch.  f.  klin.  Chir.,  1900,  Ixii. 


598     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

57.  Lexer.     Chir.  kong.  Verb.,  1907,  ii,  and  1912,  i. 

58.  Wendel.     Deutsch.  Zeitsehr.  f.  Chir.  Bd.  48,  1898. 

59.  Jaffe.     Arch.  f.  klin.  Chir.  Bd.  54,  1897. 

60.  WiLLEMS.     Surg.  Gynec.  &  Obstetrics  v,  xxviii,  June,  1919. 

61.  KONIG.    Zentrbl.  f.  Chir.,  1905. 

62.  VoLLBRECHT.     Beitr.  z.  klin.  Chir.  Bd.  21,  1898. 

63.  Schmieden.    Arch,  f .  klin.  Chir.  Bd.  62,  1900, 


CHAPTER  III 
DISLOCATIONS 

A  dislocation  is  an  abnormal  separation  of  articular  surfaces 
through  a  tear  in  the  joint  capsule.  When  the  separation  is  incom- 
plete, the  term  suhluxation  is  used. 

Dislocations  are  classified  as  traumatic,  congenital,  and  pathological 
(see  Diseases  of  Joints,  Part  V,  chap.  vii). 

The  most  frequent  cause  of  traumatic  dislocations  is  the  indirect 
influence  of  external  violence  which  results  in  dissociation  of  the 
normal  relationship  of  joint  surfaces,  greater  in  degree  than  obtains 
in  connection  with  a  sprain.  In  the  mechanism  involved  in  the  pro- 
duction of  a  dislocation,  the  bony  prominences,  the  edges  of  the  joint 
cavity,  and  the  capsule  of  the  joint  act  as  a  fulcrum,  and  the  force 
acting  upon  the  long  arm  as  a  lever  forces  the  short  arm  out  through 
a  tear  in  the  capsule. 

This  is  well  illustrated  at  the  shoulder  joint ;  forcible  abduction  of 
the  arm  causes  the  tubercle  to  impinge  upon  the  joint  fossa  and 
the  edge  of  the  acromion,  and  the  long  arm  of  the  lever  (the  humerus) 
forces  the  short  arm  (the  head  of  the  bone)  out  through  the  anterior 
portion  of  the  capsule. 

A  dislocation  is,  at  times,  produced  by  direct  violence  (without  the 
mechanism  of  lever  action).  In  these  instances  (for  example,  the 
shoulder)  the  force  is  brought  to  bear  directly  against  the  articular 
end  of  the  bone,  forcing  it  out  through  the  opposite  side  of  the 
capsule. 

Dislocations  caused  by  active  muscular  contraction  are  rare.  They 
occur  in  connection  with  sudden  violent  motions  such  as  the  act  of 
throwing,  lifting  of  a  heavy  weight,  yawning,  etc.  At  times,  joints 
may  be  voluntarily  dislocated  (especially  the  metacarpophalangeal 
joints).    Dislocations  may  also  occur  during  a  convulsion. 

An  habitual  dislocation  is  a  condition  in  which  persons  frequently 
dislocate  a  given  joint ;  it  is  probably  caused  by  the  previous  fracture 
of  a  bony  projection  normally  concerned  in  preventing  abnormal 

599 


600     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

motility,  or  it  is  sequential  to  overstretching  of  the  capsule  of  a  joint 
due  to  trauma  or  to  some  pathological  condition.  In  a  certain  number 
of  cases  it  is  fair  to  assume  that  the  tear  caused  by  the  primary  disloca- 
cation  did  not  heal,  and  thus  upon  comparatively  slight  hypermotility 
the  bone  finds  an  easy  avenue  of  egress. 

As  a  rule  the  force  that  produces  a  dislocation  decides  the  direction 
in  which  the  bone  leaves  the  joint,  so  that  it  may  be  located  at  any  of 
the  four  sides  of  the  joint,  i.  e.,  anterior,  posterior,  internal,  and 
external.  When  the  bone  leaves  the  joint  its  displacement  may  be 
increased  (secondary  clisplacemcnt)  by  the  weight  of  the  limb,  by 
contraction  of  muscles,  and  by  the  elasticity  of  the  ligaments. 

The  terminology  of  dislocations  is  based  on  the  malposition  of  the 
peripheral  bone,  i.  e.,  at  the  shoulder,  the  term  subcoraeoid  or  sub- 
glenoid dislocation  of  the  humerus  is  employed,  etc.  This  does  not,  how- 
ever, always  convey  a  proper  idea  of  the  conditions,  as  in  a  certain  num- 
ber of  instances  the  end  of  the  central  bone  punctures  the  capsule  of  the 
joint,  as  happens  in  so-called  posterior  dislocations  of  the  forearm 
where  the  lower  end  of  the  humerus  is  displaced  forward  and  in  dorsal 
luxations  of  the  fingers,  the  central  phalanx  or  the  head  of  the  meta- 
carpal bone  is  forced  out  through  the  capsule. 

When  dislocations  are  not  reduced  pain  and  swelling  gradually  dis- 
appear; a  certain  degree  of  motion  returns  and  muscular  activity 
increases;  the  fibro-articular  cartilages  undergo  shrinkage  and  are 
filled  with  proliferated  connective  tissue.  When  the  end  of  the  dis- 
located bone  rests  in  contact  with  a  bony  surface,  it  gradually  forms 
a  pseudo  joint  cavity  to  which  it  is  attached  by  an  adventitious  capsule 
formed  by  proliferated  connective  tissues.  In  some  instances  the  new 
hollow  in  which  the  bone  rests  becomes  covered  with  a  la^'er  of  fibro- 
cartilage  so  that  the  limb  may  be  capable  of  restricted  but  painless 
motion. 

The  symptoms  of  a  recent  dislocation  consist  of  severe  pain  and 
more  or  less  loss  of  function.  To  these  may  be  added  the  manifesta- 
tion consequent  to  the  faulty  position  of  the  dislocated  bone  and  the, 
modifications  this  produces  in  the  normal  landmarks  of  a  given  joint. 

The  diagnosis  is  based  on  the  character  of  the  provocative  trauma, 
the  loss  of  function,  and  the  results  of  inspection  and  palpation. 

Inspection  reveals  distortion  of  the  normal  outlines  of  the  joint, 
which  is  more  easily  recognized  when  compared  to  the  corresponding 
normal  one.  These  differences  in  outline  relate  to  the  absence  of  ^ 
normal  prominence  on  the  one  hand  and  the  presence  of  a  promi- 


DISLOCATIONS  601 

nence  where  a  depression  previously  existed.  The  malposition  of  the 
bone  causes  its  long  axis  to  become  continuous  with  a  point  distal  from 
the  joint.  Shortening  or  lengthening  occurs  in  accord  with  the  re- 
lationship the  dislocated  bone  bears  to  the  joint  surface. 

In  cases  of  moderate  effusion  of  blood,  the  diagnosis  can  be  made 
by  simple  inspection;  however,  when  much  swelling  is  present,  palpa- 
tion becomes  a  valuable  aid  in  this  connection.  The  articular  end  of 
the  luxated  hone  may  be  felt  as  a  hard  mass  contiguous  to  the  joint, 
while  at  the  site  of  the  latter  the  presence  of  a  more  or  less  dis- 
tended hollow  may  be  recognized.  Passive  motion  is  restricted  as  the 
result  of  the  tension  of  muscles  and  ligaments  which  hold  the  dis- 
placed bone  in  an  abnormal  position  and,  by  virtue  of  their  elasticity, 
interfere  with  the  resumption  of  the  normal  relationship  of  the  dis- 
sociated articular  surfaces. 

Dislocations  are  frequently  complicated  hg  fractures.  The  solution 
of  continuity  of  bone  is  often  located  near  its  luxated  articular  end, 
as  the  force  which  produces  the  dislocation  is  not  expended  when 
the  luxation  is  accomplished  but  also  fractures  the  bone.  When  a 
fracture  is  present  the  mobility  of  the  part  is  increased,  but  manipu- 
lation does  not  return  the  dislocated  part  to  its  normal  position. 
The  avidsion  of  scg))ients  of  hone  corresponding  to  the  insertion 
of  muscles  is  a  common  complication  of  a  dislocation  and,  at  times, 
is  revealed  by  the  presence  of  crepitation.  As  a  rule,  the  latter  condi- 
tion is  not  recognized  until  an  X-ray  exposure  is  made ;  however, 
simple  dislocations  should  be  recognized  without  this  aid. 

In  the  forearm  and  leg  one  bone  may  be  hrolien  and  the  other  dis- 
located. Injuries  of  nerves,  blood  vessels,  muscles,  and  tendons  are 
not  as  common  in  dislocations  as  in  fractures.  Each  of  these  is 
recognized  by  the  symptoms  peculiar  to  itself. 

In  old  dislocations  pain  and  swelling  are  absent  and  at  times  pas- 
sive motion  provokes  crepitation.  In  other  regards  the  clinical  pic- 
ture does  not  differ  from  that  described  in  connection  with  fresh 
dislocations. 

The  treatment  of  dislocations  consists  of  replacement  of  the  dis- 
located bone  into  its  normal  position.  Although  the  method  of  re- 
ducing a  dislocation  varies  with  the  anatomical  conditions  and  the 
particular  joint  involved  in  the  problem,  there  are  certain  fundamental 
principles  applicable  to  all  injuries  of  this  sort.  In  all  instances  the 
secondary  displacement  of  the  bone  must  be  overcome  by  placing  the 
limb  in  a  position  which  relaxes  the  tense  muscles  and  ligaments.   Tiie 


602     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

untorn  portion  of  the  capsule  is  the  greatest  hindrance  to  reposition, 
therefore  the  limb  should  be  placed  in  the  position  it  occupied 

WHEN  THE  DISLOCATION  OCCURRED,  AND  THE  REPOSITION  ACCOMPLISHED 
BY  REVERSING  THE  FORCE  THAT  ORIGINALLY  DISSOCIATED  THE  ARTICULAR 

SURFACES,  In  the  manipulation,  the  shaft  of  the  hone  is  used  as  a  lever 
and  the  fist  of  an  assistant  as  the  fulcrum. 

The  narcotic  state  relaxes  the  muscles  and  obviates  resistance  due 
to  pain  and  renders  easier  the  reduction  of  all  dislocations.  It  should 
be  emplo^^ed  whenever  possible. 

The  earlier  reduction  is  attempted  the  less  difficult  is  its  accomplish- 
ment. In  old  cases  preliminary  manipulations  which  loosen  adhesions 
and  stretch  the  muscles  are  of  great  assistance. 

When  reduction  is  accomplished,  the  joint  should  be  immobilized  for 
from  eight  to  ten  days,  at  the  end  of  which  time  the  scar  in  the  cap- 
sule is  healed  and  passive  and  active  motion  and  massage  may  be 
begun.  At  first  the  motion  that  produced  the  dislocation  should  be 
avoided;  a  precaution  which,  when  neglected,  may  reopen  or  stretch 
the  tear  in  the  capsule. 

Function  returns  very  quickly  in  simple  dislocations  which  are 
reduced  early.  When  segments  of  bone  have  been  avulsed,  or  when 
there  is  much  effusion  of  blood  in  the  contiguous  soft  parts,  more  or 
less  permanent  impairment  of  function  is  likely  to  follow  (Lexer^). 

The  reduction  of  dislocations  hij  manipulation  is  rendered  impossible 
when  the  tear  in  the  capsule  is  small  and  tightly  grips  the  head  of 
the  displaced  bone,  or  when  the  head  of  the  bone  is  incarcerated  by 
tendons  (luxatio  pollicis),  or  when  segments  of  joint  capsule  or  muscle, 
with  or  without  portions  of  avulsed  bone,  are  interposed  {luxatio 
humeri). 

In  these  cases  the  open  method  of  reduction  must  be  resorted  to. 
The  tear  in  the  capsule  is  exposed  and  enlarged,  or  the  agent  which 
interferes  with  reduction  is  removed.  In  old,  unreducible  dislocations, 
a  similar  procedure  is  executed.  The  dislocated  bone  is  exposed,  ad- 
hesions are  severed,  the  articular  surface  cleared  of  proliferated  tis- 
sue, and  the  bone  replaced  in  its  normal  position.  The  earlier  opera- 
tive methods  of  correction  are  used  in  unreducible  dislocations  the 
more  favorable  is  the  outcome. 

Dislocations  complicated  by  fractures  present  a  difficult  problem. 
In  cases  of  simple  avulsion  of  segments  of  bone,  reduction  is  not  always 
difficult;  but  when  epiphyseal  separation  or  diaphyseal  fracture  are 
present,  reduction  by  manipulation  rarely  succeeds.    In  these  cases, 


DISLOCATIONS 


603 


operaiive  exposure  of  the  lesion,  open  reduction  of  the  dislocation, 
and  suture  of  the  hone  are  indicated.  Postponement  of  reduction  until 
the  fracture  is  healed  is  unwise ;  the  delaj'ed  effort  at  replacement  usu- 
ally fails  or  results  in  refracture.  In  old  cases  with  grave  interference 
with  function,  resection  of  the  articular  end  of  the  dislocated  hone 
becomes  necessary. 

Dislocations  of  the  Lower  Jaw. — Forward  Dislocations. — Bilateral 
dislocation  of  the  lower  jaw  is  not  infrequent.    It  is  caused  by  exces- 
sive   opening    of    the 
mauth,  yawning,  vomit- 
ing, etc.    Normally  the 
head  of  the  articular 
processes     leaves     the 
glenoid  fossa  and  rests 
on  the  eminentia  artic- 
ularis,  so  that  but  little 
force    is    required    to 
cause  the  former  to  slip 
in  front  of  the  latter. 
The  action  of  the  ex- 
ternal   pterygoid    and 
temporal  muscles  fixes 
the  head  of  the  bone  in 
its  new  environment. 
The    symptoms    are 
■^  clearly    defined.      The 
mouth  is  widely  open, 
the  patient  is  unahle  to 
close  the  mouth.     The 
condyloid  process  may 
be  felt  in  front  of  the 
glenoid  cavity.  In  uni^ 
lateral  dislocation,  the 
mouth   is   also   widely 
opened  and  the  chin  is 
pushed  toward  the  normal  side.    As  a  rule,  the  capsule  is  not  raptured 
but  is  strongly  stretched.    The  dislocation  does  not  occur  in  children. 
The  prognosis  is  good,  however,  some  cases  show  a  tendency  to 
hahitual  dislocation. 

Beduction  is  accomplished  by  making  downward  pressure  upon  the 


Fig. 


tkl^^lTftt^. 


196. —  Eeduction  of  Dislocation  of  Lower 
Jaw. 


604     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

alveolar  processes  of  the  bone  (Fig.  196)  followed  by  backward  pres- 
sure. In  this  way  the  head  of  the  bone  is  placed  upon  the  articular 
tubercle  and  reduction  is  accomplished.  The  latter  is  attended  with  a 
sudden  relaxation  of  resistance.  Narcosis  is  not  usually  necessary. 
The  thumbs  of  the  surgeon  should  be  protected. 

Backward  Dislocation. — Dislocation  backward  of  the  lower  jaw  is 
very  rare.  It  occurs  mostly  in  women.  The  condyloid  processes  slip 
over  the  small  tympanic  tubercle  situated  at  the  anterior  edge  of  the 
anterior  glenoid  cavity  and  enter  the  tympanico-stylomastoid  fossa. 
The  mouth  is  held  firmly  closed ;  the  teeth  of  the  lower  jaw  are  pressed 
tightly  behind  those  of  the  upper. 

Reduction  is  easily  accomplished  by  pushing  the  lower  jaw  back- 


FiG.  197. —  A,  Presternal,  Dislocation  of  Clavicle;  B,  Eetrosternai/ 
Dislocation  of  Clavicle. 


ward  and  then  forward,  or  by  forcible  opening  of  the  jaw  by  means 
of  a  pointed  stick  or  other  suitable  lever. 

Dislocation  of  the  Vertebrae. — This  is  taken  up  with  surgery  of  the 
spine  (Part  IX). 

Dislocation  of  the  Ribs. — This  condition  need  only  be  mentioned. 
It  occurs  at  the  sternal  end  of  the  rib  and  is  easily  reduced  by  direct 
pressure. 

Dislocations  of  the  Clavicle. — Dislocations  of  the  Sternal  End  of 
THE  Clavicle. —  This  extremity  may  be  displaced  anteriorly  (pre- 
sternal) and  upward  (suprasternal) .  Both  conditions  are  due  to  in- 
direct violence ;  when  the  first  rib  acts  as  a  fulcrum,  and  when  force 


DISLOCATIONS 


605 


is  directed  against  the  shoulder,  either  directly  inward  or  from  "be- 
hind. 

Posterior  dislocation  is  rare  and  is  due  to  direct  violence. 
The  diagnosis  is  readily  made  by  palpation.     The  posterior  dislo. 
cation  may  i^roduee  pressure  on  the  trachea  and  esophagus.     Diifer- 
eutiation  from  fracture  of  the  clavicle  near  the  sternal  end  demands 
careful  palpation. 

Reduction  is  easy;  however,  retention  in  the  corrected  position  is 
less  so.  Direct  pressure  on  the  bone  is  necessary  (see  fracture  of 
clavicle) .  When  this  fails,  fixation  by  suture,  etc.  (p.  790) ,  is  indicated. 

Dislocation  of  the  Ac- 
romial End  of  the  Clav- 
icle.—  This  end  may  be 
forced  upward  {supra- 
acromial,  Fig.  198)  and 
downward  {infra-acromial)  ; 
the  latter  is  very  rare. 

The  former  is  caused  by 
violence  directed  against  the 
acromion  with  the  clavicle 
fixed.  The  condition  is 
really  a  downward  disloca- 
tion of  the  scapula.  The 
dislocation  is  complete  when 
the  coracoclavicular  liga- 
ment is  torn. 

The  diagnosis  is  based  on 
careful  palpation.  The  con- 
dition is  not  rarely  mistaken 
for  a  dislocated  humerus  but  is  still  more  often  confused  with  fracture 
of  the  acromial  end  of  the  clavicle.  The  differential  diagnosis  is 
assisted  by  following  the  lines  of  both  spines  of  the  scapulae  with  the 
thumbs  and  by  exact  measurements  of  the  two  clavicles.  Of  course 
the  X-ray  makes  the  diagnosis  easy. 

Reduction  is  easy  but  retention  is  not.  For  the  purpose,  the  reduced 
dislocation  is  dressed  as  for  fracture  (p.  690)  and  a  pad  is  placed 
over  the  injury.  It  may  be  necessary  to  fix  the  part  by  operative 
measures,  such  as  nailing  and  suture  of  the  ligaments. 

Dislocations  of  the  Shoulder. —  Dislocations  in  this  situation  occur 
almost  as  frequently  as  do  all  the  others  put  together.     They  are  not 


Fig.  198. —  Dislocation  of  Acromial  End 

OF  CLA\aCLE. 


606     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

difficult  to  recognize,  yet,  many  remain  unreduced  because  of  failure 
to  make  the  diagnosis. 

Normally,  palpation  of  the  shoulder  joint  reveals  tlie  acromion 
process  and  its  connection  with,  the  clavicle ;  beneath  this  is  the  cora- 
coid  process  and  lower  still  the  head  of  the  humerus  beneath  the 
deltoid  muscle.  When  the  humerus  is  rotated,  the  tubercles  and,  at 
times,  the  sulcus  between  them,  may  be  felt.  In  the  axilla,  the  edge 
of  the  glenoid  cavity  alid  the  head  of  the  humerus  -may  be  plainly 
made  out.  The  normal  relationship  of  the  joint  surfaces  is  not  main- 
tained by  the  capsules  and  the  ligaments,  but  by  the  musculature  and 
by  air  pressure.  When  the  deltoid  muscle  is  paralyzed  the  head  of 
the  humerus  sinks  more  or  less  away  from  the  glenoid  cavity,  a  con- 
dition of  affairs  plainly  visible  through  the  atrophied  muscle. 

Anterior  Dislocation  of  the  Humerus. —  Anterior  dislocations  of 
the  humerus  (Fig.  199)  are  preglenoid,  suhcoracoid  or  subclavicular, 
according  to  the  degree  of  displacement.  On  the  cadaver  the  disloca- 
tion is  easily  produced  b}^  gradually  but  forcibly  elevating  the  arm 
(exaggerated  abduction).  In  this  way,  the  inner  portion  of  the  cap- 
sule (where  it  is  thinnest)  is  stretched  and  the  head  of  the  bone  tears 
through  it  and  luxates  to  beneath  the  coracoid  process.  When  the 
arm  is  allowed  to  drop,  all  the  objective  signs  (except  ecchymosis)  are 
present. 

The  dislocation  is  occasionally,  produced  by  direct  injury  but  usu- 
ally follows  indirect  force,  i.  e.,  a  fall  on  the  side  while  the  arm  is 
abducted  or  upon  the  outstretched  hand  or  on  the  elbow,  especially 
when  the  arm  is  overextended.  It  also  results  from  muscular  action 
(throwing).  When  the  indirect  force  is  severe,  excessive  abduction 
brings  the  arm  in  contact  with  the  scapula;  the  tubercle  and  the 
neck  of  the  humerus  impinge  upon  the  upper  edge  of  the  joint  fossa 
and  the  acromion,  and  the  short  end  of  the  lever  —  the  head  of  the 
bone  —  is  forced  out  of  the  joint  pan.  Dislocations  of  this  sort  are 
primarily,  more  or  less,  subglenoid,  but  secondary  displacement 
(muscular  action,  etc.)  causes  the  head  of  the  humerus  ultimately  to 
repose  beneath  the  coracoid  process. 

In  anterior  dislocation,  the  head  of  the  humerus  lies  close  to  the 
edge  of  the  glenoid  cavity,  between  it  and  the  ribs,  and  is  very  likely 
to  make  pressure  upon  the  axillary  vessels  and  nerves. 

The  symptoms  of  typical  subcoracoid  dislocation  are  very  char- 
acteristic (Fig.  199).     They  are  all  based  upon  the  fact  that  the  head 


DISLOCATIONS 


607 


Fig,  199. —  Subcoeacoid  Dislocation  of  the  Humerus. 

The  malposition  is  of  two  weeks  standing;  the  swelling 
has  disappeared,  making  visible  the  landmarks  of  the 
joint.  The  acromion  protrudes,  the  arm  is  abducted  and 
forms  the  outer  line  of  a  triangle.  The  long  axis  of  the 
arm  terminates  at  the  coracoid  (instead  of  at  the  acromion). 
The  protrusion  below  the  coracoid  is  produced  by  the  mal- 
placed  head  of  the  humerus. 


of  the  bone  no  longer  occupies  the  joint  cavity  and  is  in  an  abnormal 
position. 

The  examination  is  always  begun  with  inspection,  which  is  often 
sufficient  for  the  purpose,  so  that  palpation  is  employed  simply  for 


GOS     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

the  purpose  of  verification  of  the  diagnosis.  The  patient  is  seated  in 
a  chair  (without  a  back)  and  stripped  to  the  waist,  so  that  the  two 
sides  of  the  body  may  be  compared.  The  injured  arm  should  be  placed 
in  a  position  as  close  to  that  of  the  sound  one  as  is  possible. 

The  round  contour  of  the  shoulder  is  absent,  the  acromion  presents 
a  sharp-cornered  projection.  (The  dome  of  the  shoulder  is  formed  by 
the  head  of  the  humerus  and  the  deltoid  muscle.)  The  acromion  is 
readily  identified  by  following  its  continuation  with  the  spine  of  the 
scapula. 

An  ah  normal  prominence  is  both  visible  and  palpable  in  the  region 
below  the  coracoid  process.  Rotation  of  the  arm  shows  this  to  consist 
of  the  head  of  the  humerus. 

The  arm  is  postured  in  elastic  abduction;  it  may,  by  the  use  of 
force,  be  brought  in  contact  with  the  thoracic  wall,  but,  when  released, 
reassumcs  the  abducted  position.  This  is  due  to  the  tension  of  the 
stretched  coracohuraeral  ligament  and  of  the  muscles  inserted  into  the 
tubercles. 

The  long  axis  of  the  arm  is  continuous  with  the  coracoid  processes 
or  the  clavicle.  This  is  especially  noticeable  when  compared  to  the 
sound  side. 

The  outer  contour  line  of  the  arm  seems  to  be  dented.  This  ''dent" 
forms  the  apex  of  an  obtuse  triangle,  the  upper  line  of  which  is  formed 
by  the  tense  deltoid  muscle,  the  lower  by  the  arm  itself,  while  the  base 
is  directed  outward  (i.  e.,  a  line  drawn  from  the  acromion  to  the 
external  condyle  of  the  humerus). 

The  humerus  appears  elongated;  the  distance  between  the  acromion 
and  the  external  epicondyle  is  increased.  This  is  especially  noticeable 
from  behind  and  is  due  to  the  position  the  head  of  the  luxated  bone 
occupies,  wdiich  is  lower  than  when  it  is  in  the  joint  cavity. 

The  head  of  the  bone  is,  more  or  less,  plainly  palpable  in  its  faulty 
position.     Passive  motion  is  painful ;    active  motion  much  restricted. 

The  complications  consist  in  avulsion  of  portions  of  bone  from  the 
major  tubercle,  and  injury  to  vessels  and  nerves.  The  nerves  are 
always  subjected  to  great  tension  and,  at  times,  are  severely  crushed 
when  caught  between  the  head  of  the  bone  and  the  thorax.  The 
axillary  nerve  is  most  likely  to  be  injured,  and  is  followed  by  paralysis 
of  the  deltoid  muscle. 

The  diagnosis,  when  the  signs  and  symptoms  stated  are  carefully 
weighed, .  is  not  difficult.  In  doubtful  cases  the  X-ray  may  be  em- 
ployed, or  an  examination  may  be  resorted  to  under  narcosis. 


DISLOCATIONS  609 

The  differential  diagnosis  includes : 

Contusions  of  the  shoulder  and  sprains  which  do  not  show  evidence 
of  malposition. 

In  supra-acromial  dislocaiion  of  the  clavicle,  the  protruding  anerle 
at  the  shoulder  is  formed  by  the  collar  bone,  not  by  the  acromion ; 
the  arm  is  not  abducted ;  the  curve  of  the  shoulder  is  maintained. 

In  fractures  of  the  neck  of  the  scapula  the  acromion  is  prominent, 
the  head  of  the  bone  is  dropped  downward  and  forward  but  simple 
lifting  of  the  arm  corrects  the  deformity.     Crepitus  is  usually  felt. 

In  paralysis  of  the  deltoid  muscle  the  shoulder  droops,  which  is 
corrected  by  lifting  the  arm.     The  latter  is  not  abducted. 

In  fractures  of  the  surgical  neck  of  the  humerus  the  curve  of  the 
shoulder  is  not  lost,  even  when  the  upper  end  of  the  shaft  is  dislocated 
and  the  arm  abducted.  The  arm  is  not  held  in  elastic  abduction  and 
is  never  lengthened;   on  the  contrary,  shortening  is  present. 

The  prognosis  in  uncomplicated,  early  reduced  cases  is  good.  How- 
ever, complete  return  of  function  in  the  joint  is  probably  never 
attained. 

Early  reduction  is  imperative.  As  a  rule,  this  is  not  difficult  and 
may  be  accomplished  without  narcosis.  When  this  does  not  succeed 
at  once,  narcosis  should  be  employed  without  delay.  Of  the  many 
methods  of  reduction  the  following  are  recommended : 

1.  Extension  of  the  ahducfed  arm  (with  the  patient  lying  down) 
and  counter  extension  b}'  means  of  a  broad  cloth  passed  around  the 
chest  are  made.  This,  supplemented  by  direct  pressure  on  the  head 
of  the  bone  in  the  direction  of  'he  glenoid  cavity,  often  accomplishes 
reposition. 

The  well  known  method  of  Cooper  is  valuable.  The  surgeon  grasps 
the  wrist  "of  the  luxated  extremity  and  makes  traction  in  the  long  axis 
of  the  body,  while  the  foot  (without  a  shoe)  is  placed  in  the  axilla  and 
makes  direct  pressure  on  the  head  of  the  bone. 

Extension  ly  hyperal)ducti<^. —  The  patient  is  placed  on  the  floor 
and  the  arm  is  drawn  upward  by  an  assistant  who  sits  behind  the 
patient.  The  surgeon  makes  pressure  on  the  head  of  the  bone  in  the 
axilla. 

In  the  pendulum  method,  the  patient  lies  on  the  floor  and  is  lifted 
by  the  luxated  arm.  The  weight  of  the  body  acts  on  the  head  of  the 
bone  upon  which  pressure  is  made  with  the  fist.  This  may  be  reversed 
by  applying  weights  to  the  pendulous  arm. 

2.  Reduction   hy   manipulation    (Kocher)    consists   of   four   acts. 


610     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


r 

"/^^^-  ^ 

^m^ 

^>r. 

t^- 

L 

1 

C  D 

Fig.  200. —  Anatomical  Preparation  Showing  Reduction  of  Subcoracoid 
Dislocation  of  the  Humerus  (Kocher's  Method). 

A,  The  arm  is  adducted  until  the  elbow  touches  the  thorax.  This  does  not  alter 
the  position  of  the  head  of  the  bone;  B,  with  the  arm  held  adducted,  the  elbow  is 
flexed  to  a  right  angle;  the  forearm  is  used  as  a  lever  and  the  arm  rotated  ex- 
ternally until  the  forearm  protrudes  at  a  right  angle  from  the  body.  The  tear 
in  the  capsule  is  visible ;  the  head  of  the  bone  has  been  moved  toward  the 
acromion  and  away  from  the  brachial  plexus ;  C.  without  modifying  adduction  or 
external  rotation,  the  arm  is  elevated,  i.e.,  lifted  forward  and  the  reduction  is 
begun;  D,  the  arm  is  rotated  and  the  reduction  is  completed. 


DISLOCATIONS 


611 


which  are  very  clearly  depicted  in  Fig.  200  and  explained  in  the 

legend. 

This  method  often  succeeds  without  the  employment  of  narcosis. 

Reduction  is  attended  with  a  more  or  less  distinct  "snap"  and  by 

return  of  the  normal  range  of  motion  and  correction  of  the  deformity. 
After  reposition,  the  arm  is  fixed  with  the  hand  resting  on  the  oppo- 
site shoulder  (Fig.  201). 
This  may  be  accom- 
plished by  means  of 
bandages  or  plaster ;  the 
axilla  of  the  injured  side 
should  be  padded  with 
cotton.  Passive  motion 
is  begun  on  the  eighth 
day  after  the  reduction. 
Return  to  working 
capacity'  should  be 
achieved  by  the  fourth 
or  fifth  week. 

"When  efforts  at  reduc- 
tion are  unsuccessful, 
an  attempt  to  accom- 
plisli  it  under  deep 
narcosis  should  be  made 
at  once.  It  may  be 
necessary  to  enlarge  the 
,tear  in  the  capsule  by 
manipulation,  in  order 
to  accomplish  .reposition. 

Fig.  201.— Simple  and  Effective  ^Iethod  of  Fix-    "^^^en   success.ive   efforts 
ixG  THE  ARii  AFTER  Keduction  OF  A  DISLOCATED   by  the  various  methods 

Humerus.  -it  -        •         r.    ' 

including  extension  for 

one  hour,  do  not  achieve  reposition,  the  open  operation  is  indicated. 

When  the  dislocation  is  not  reduced,  serious  interference  with  func- 
tion is  the  result.  The  formation  of  pseudoarthrosis  is  infrequent ;  as 
a  rule,  the  joint  remains  stiff  and  painful.  In  these  cases  open  reduc- 
tion or  resection  of  the  joint  is  indicated. 

Habitual  dislocation  is  not  infrequent.  Operative  measures  of  relief 
are  indicated  (p.  815). 

Varieties  and  Complications  of  Preglenoid  Luxations. —  When 


612     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

the  head  of  the  humerus  is  dislocated  forward  it  lies  between  the 
scapula  and  the  subscapular  muscles,  and,  as  a  rule,  the  articular  sur- 
face remains,  in  part,  in  contact  wdth  the  edge  of  the  glenoid  cavity. 
In  this  event,  mutual  destruction  of  the  apposed  surfaces  occurs  in  a 
few  weeks.  As  time  goes  on  destruction  of  the  head  of  the  bone  takes 
on  the  form  of  a  deep  gutter,  while  the  anterior  half  of  the  surface  of 
the  glenoid  is  made  smooth.     At  the  same  time,  the  periosteum  is  con- 


FiG.  202. —  Unreduced  Subcoracoid  Dislocation  of  Humerus. 

The  rumerus  is  rotated  forward,  showing  its  posterior  surface.  The  glenoid 
cavity  is  partially  destroyed  by  pressure.  The  area  destroyed  is  covered  with 
proliferated  bone  which  is  hollowed  out.  The  head  of  the  humerus  shows  a  deep 
sulcus  (from  pressure).  The  surface  of  the  sulcus  and  the  contiguous  portion  of 
the  surgical  neck  of  the  humerus  is  covered  with  proliferated  bone. 


cerned  in  active  proliferation  which  forms  an  inadequate  false  joint 
(Fig.  202) .  Under  these  circumstances  reposition  is  difficult  and  often 
is  not  accomplished  by  the  open  method. 

Supracoracoid  dislocation  is  extremely  rare  and  is  alwaj's  compli- 
cated by  fracture  of  the  coracoid  process. 

Dislocation  with  fracture  of  the  greater  tubercle.  The  diagnosis  is 
only  possible  by  means  of  the  Rontgenogram. 

Dislocation  with  fracture  of  the  neck  of  the  humerus  is  a  serious 


DISLOCATIONS 


613 


injury.     When  reduction  by  manipulation  does  not  succeed,  it  is  best 
to  resort  to  arthrotoni}'  witliout  delay. 

SuBGLEXoiD  OR  AxiLLARY  DiSLOCATiox  (Fig.  203). —  In  this  variet}' 
the  head  of  the  humerus  lies  in  contact  with  the  lower  edge  of  the 
glenoid  cavity  and  is  palpable  in  the  axilla.  When  the  arm  is  elevated, 
the  line  of  the  arm  and  the  shoulder  assumes  a  characteristic  bayonet 
shape.  The  acromion  is  prominent  and  the  joint  cavity  is  empty.  At 
times,  the  arm  is  held  in  a  horizontal  position  {luxatio  erecta).     Repo- 


FlG. 


203. —  RONTGEXOGRAJI      OF      SUBGLENOID      DISLOCATION     OF 

Humerus.     (Harlem  Hospital  case). 


sition  is  easily  accomplished  by  making  traction  on  the  arm  while 
pressure  is  made  in  the  axilla. 

Backward  Dislocation  of  the  Humerus. —  Dislocation  backward 
of  the  humerus  {retroglenoid,  sultacromial,  infraspinal)  is  rare  and  is 
due  to  direct  violence.  The  head  of  the  bone  may  be  seen  and  felt  in 
its  abnormal  position.  Reduction  is  accomplished  by  traction  on  the 
arm,  together  with  abduction  and  direct  pressure. 

Dislocations  of  the  Elbow  Joint. —  For  the  purpose  of  intelligentlii 
examining  luxations  of  the  dhow  joint  a  knowledge  of  its  normal 
contour  is  essential.     The  epicondyles,  the  olecranon,  and  the  relation- 


614     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

ship  these  bear  to  each  other  in  varying  positions  of  the  joint,  and  the 
presence  of  the  head  of  the  radius  beneath  the  external  condyle,  are 
readily  recognized  by  palpation.  In  dislocations,  the  articular  surfaces 
of  the  bones,  the  concavity  in  the  head  of  the  radius,  the  capituluni 
humeri,  the  trochlea,  and  the  upper  end  of  the  ulna  are  often  distinctly 
palpable.  A  satisfactory  examination  is  only  possible  when  the  rela- 
tionship that  all  these  hony  prominences  hear  to  one  another  is  taken 
into  account. 

Dislocations  at  the  elbow  joint  are  divided  into  those  of  loth  hones 
(luxatio  antibrachii)  and  of  07ie  hone  of  the  forearm  {luxatio  radii, 
luxatio  ulnce). 

Posterior  Dislocation  of  the  Elbow. —  Posterior  dislocation  of 
the  elbow  (luxatio  antebraehii  posterior)  is  easily  produced  in  the 
cadaver.  Hyperextension  tears  the  capsule  of  the  joint  in  front  and 
the  olecranon  impinges  upon  the  posterior  supratrochlear  fossa  (fossa 
olecrani).  When  the  bones  of  the  forearm  are  used  as  a  lever  and 
the  elbow  is  flexed,  slight  backward  pressure  produces  the  luxation. 
Additional  flexion  is  prevented  by  the  impingement  of  the  coronoid 
process  upon  the  articular  surface  of  the  humerus  and  the  tension  of 
the  triceps. 

In  the  living  the  dislocation  is  often  produced  in  a  similar  manner. 
It  is  also  caused  by  forcible  lateral  motion  and  by  violence  directed 
against  the  side  of  the  lower  end  of  the  humerus. 

The  symptoms  are  clearly  defined.  The  lower  end  of  the  humerus 
may  be  felt  in  the  bend  of  the  elbow  beneath  the  muscles.  When  the 
soft  parts  are  much  torn  it  may  be  felt  beneath  the  skin.  The  long 
axis  of  the  humerus  meets  the  forearm  several  inches  below  the  normal 
position  of  the  elbow  joint.  The  olecranon  and  the  head  of  the  radius 
are  directly  palpable.  The  epicondjdcs  are  located  at  an  abnormal 
distance  from  the  olecranon.  The  lower  end  of  the  humerus  does  not 
permit  of  abnormal  motility,  as  occurs  in  connection  with  supracondy- 
loid  fracture.  The  humerus  is  not  shortened.  Traction  on  the  fore- 
arm does  not  overcome  the  deformity. 

The  diagnosis  is  difficult  when  the  dislocation  is  complicated  by 
fracture  of  the  coronoid  process,  and  when  a  supracondyloid  fracture 
of  the  humerus  or  a  fracture  of  the  olecranon  are  present.  When  the 
trochlea  is  fractured  this  fragment  may  be  displaced  backward  and 
the  head  of  the  radius  dislocated  posteriorly  at  the  same  time. 

The  prognosis  is  determined  by  the  complications.  In  simple  cases 
reposition  is  followed  by  return  of  function. 


DISLOCATIONS 


615 


The  method  of  reduction  is  shown  in  Figs.  204,  205,  206,  207.  Like 
luxations  of  all  hinge  joints,  reposition  is  not  attainable  by  even  the 
most  forcible  traction.  Reduction  must  be  accomplished  without  the 
least  force,  the  patient,  if  possible,  being  narcotized  for  the  purpose. 
The   forearm   is   supinated   and   overextended,   the   latter   maneuver 


Fig.    204. —  Hyperextension   of   Forearm. 
First  act  of  reposition  maneuver. 

releasing  the  coronoid  process  from  the  olecranon  fossa.  Following 
this,  extension  is  made  on  the  forearm  while  the  other  hand  steadies 
the  injured  elbow  joint  and  makes  "encircling  pressure"  in  the  gen- 
eral direction  of  the  reposition.  This  is  succeeded  by  gradual 
unimpeded  flexion,  and  the  dislocation  is  corrected. 


Fig.  205. —  Skeletal  Eepresentatiox  of  Fig.  204. 

The  olecranon  is  the  fulcrum  of  the  lever.     The  leverage  acts  on  the  forearm 
in  the  direction  of  the  arrow. 


The  after  treatment  consists  in  immobilization  for  fourteen  days, 
during  which  the  dressing  is  to  be  changed  repeatedly  and  the  joint 
gentl}'  massaged. 

Lateral  Dislocation  of  the  Elbow  (hixatio  hrachii  lateralis). — 
This  is  not  rare.  The  outer  (Figs.  208-209)  is  more  frequent  than 
the  inner;  the  former  is  usually  attended  with  avulsion  of  the  inner 


616     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Fig.   206. —  Effect  of  Hyperextension 

ON     THE    EelATIONSHIP     OF     THE     MaL- 

PLACED  Bones. 


epicondyle  (somewhat  analogous  to  Pott's  fracture).  The  bone 
injury  may  be  due  directly  to  the  trauma  which  caused  the  luxation, 
or  the  epicondyle  may  be  avulsed  by  the  drag  of  the  lateral  ligament 
upon  the  epicondyle.  In  a  similar  manner,  inward  dislocation  of  the 
forearm  may  be  attended  with  avulsion  of  the  external  epicondyle. 

As  a  rule,  the  forearm  remains 
in  abnormal  contact  with  the 
humerus.  In  outward  dislocations 
the  ulna  is  in  contact  with  the 
eminentia  capitata  and  the  head 
of  the  radius  is  free.  Usually  the 
forearm  is  also  displaced  hack- 
ward,  so  that  a  combination  dis- 
location is  effected  (luxatio  pos- 
terior    externa     or    posterolater- 

alis).       While    the    posterior    dis-  The  coronoid  process  is  delivered  from 

placement     does     not     necessarily  tiie      posterior     fossa.        The     reposition 

,            J.1        1    .        1     T               .        /xi  maneuver  now   consists   in   circular  trac- 

tear^  the^  lateral    ligaments    (the  ti^n  in  the  direction  of  the  arrow. 

median  ligament  is  usually  torn), 

lateral  displacement  is  attended  with  considerable  laceration  of  the 

ligaments  or  with  avulsion  of  one  of  the  epicondyles. 

The  form  of  dislocation  just  described  is  also  designated  as  incom- 
plete in  contrast  to  the  complete  in  which  no  two  of  the  articular  sur- 
faces remain  in  contact. 

Lateral  luxations  are  always 
caused  hy  lateral  "kinking'*  at  the 
elbow  in  the  direction  of  abduction 
or  adduction.  The  capsule  is  exten- 
sively torn. 

The  symptoms  of  complete  lateral 
luxation  are  unmistakable. 

In    incomplete    outward    disloca- 

tion,    the    abnormal    prominence    of 

the  head  of  the  radius  is  visible  and 

plainly  palpable.     On  the  inner  side  the  trochlea  may  be  distinctly 

felt  and  the  avulsed  epicondyle,  or  a  protruding  normal  one,  may  also 

be  made  out.    Examination  is  much  facilitated  by  narcosis. 

In   incomplete   inward    dislocation    (luxatio    posteromedialis)    the 
epicondyle  is  either  very  prominent  or  is  avulsed.     The  ulna  is  visible 


Fig.  207. 

CULAR 

206   IS 

TION. 


—  The  Effect  of  the  Cir- 
Traction  Shown  in  Fig. 
TO   Complete   the   Eeposi- 


The    arrow   indicates 
of  the  final  traction. 


the    direction 


DISLOCATIONS 


617 


and  palpable  to  the  inner  side.     The  head  of  the  radius  lies  in  contact 
with  the  trochlea ;   the  capitellium  is,  however,  partially  palpable. 
The  prognosis  depends  upon  the  complications. 


Fig.  208. —  Eontgenogram  op  Outward  Dislocation  of  Forearm. 
The  protrusion  of  the  head  of  tlie  radius  shows  very  plainly.     The  dislocation 
was  produced  by  a  fall  upon  the  hand,  which  also  fractured  the  radius.     (Supra- 
condyloid  fracture  of  radius;   Harlem  Hospital  case.) 

Reposition  should  be  accomplished  under  narcosis.  The  forearm  is 
hyperextended,  downward  traction  is  made  together  with  direct  lateral 
pressure  with  the  hand  upon  the  upper  end  of  the  forearm.  When 
interposition  of  soft  parts  interferes  with  reduction,  extended  motion 


Fig.  209. —  Lateral  View  of  Fig.  208,  Showing  the  Separation  of  the  Joint 
Surfaces.     (Harlem  Hospital  case.) 

(hyperextension  and  abduction)  may  release  the  bone.  When  efforts 
at  reposition  are  unsuccessful,  the  joint  must  be  opened,  preferably 
by  two  lateral  incisions.  The  results  following  the  open  operation 
are  good. 


618     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

Anterior  Dislocation  of  the  Forearm  {luxatio  antebrachii 
anterior). — The  forearm  is  displaced  anteriorly  in  this  variety.  This 
is  a  rare  luxation  and  is  usually  attended  with  fracture  of  the  ole- 
cranon. It  may  be  produced  by  a  blow  or  a  fall  upon  the  olecranon 
when  the  elbow  is  fully  flexed. 

Symptoms. —  The  normal  protrusion  of  the  olecranon  is  lost  and 
the  lower  end  of  the  humerus  is  felt  in  its  place.  When  the  outer  side 
of  the  olecranon  is  still  in  contact  with  the  trochlea  (the  arm  is  ex- 
tended), the  luxation  is  incomplete.  In  a  complete  luxation  the  end 
of  the  olecranon  rests  in  front  of  the  articular  surface  of  the  lower 
end  of  the  humerus  (the  arm  is  acutely  flexed).  Reducticm  is  accom- 
plished by  means  of  gentle  extension  and  moderate  pressure. 

Diverging  Dislocation. —  In  diverging  dislocation  {luxatio  ante- 
hranchii  divergens)  the  ulna  is  displaced  backward  and  the  radius 
forward,  so  that  the  humerus  is  driven  between  them  like  a  wedge. 
The  injury  is  very  rare.  The  abnormal  positions  of  the  bones  are 
readily  palpable.  In  reducing  the  deformity  each  bone  is  treated 
separately.  The  ulna  is  reduced  by  hyperextension  and  traction; 
the  radius  by  direct  pressure. 

Isolated  Dislocation  of  the  Ulna. —  Though  uncommon,  it  may  be 
produced  by  a  fall  upon  the  hand  during  overextension  of  the  pro- 
nated  forearm.  The  symptoms  are  similar  to  those  produced  by 
posterior  dislocations  of  both  bones,  except  that  the  head  of  the  radius 
is  not  displaced  ;  the  elbow  is  held  in  the  varus  position.  Reposition 
by  hyperextension  and  traction. 

Isolated  Dislocation  of  the  Radius. —  This  is  not  as  rare  as  that 
of  the  ulna.  It  occurs  in  various  forms,  i.  e.,  in  front,  backward,  and 
outtcard. 

The  outer  luxation  is  usually  a  complication  of  fracture  of  the  ulna 
in  its  upper  third.  The  head  of  the  bone  may  be  palpated  at  the 
outer  edge  of  the  condyle ;  the  radial  side  of  the  forearm  is  shortened ; 
the  elbow  is  in  the  valgus  position.  Reposition  by  direct  pressure. 
Immobilization  with  the  forearm  in  varus  position. 

Backward  luxation  is  rare;  the  capitulum  radii  is  readil}^  felt  in 
the  abnormal  position.  The  elbow  is  fixed  in  half  pronation ;  active 
extension  and  supination  are  lost.  Reposition  by  direct  pressure  and 
sharp  traction. 

Anterior  luxation  is  not  infrequent.  It  is  produced  by  a  direct  blow 
against  the  capitulum  radii  from  behind,  or  by  a  fall  upon  the  hand 
with  the  forearm  in  pronation.     The  head  of  the  radius  rests  in  front 


DISLOCATIONS  619 

of  the  capitulum  humeri  (Fig.  210)  and  causes  a  bulging  in  the  area 
of  the  supinator  muscles.  The  forearm  is  slightly  flexed  and  pro- 
nated.  Active  supination  is  unattainable ;  flexion  to  a  right  angle 
may  be  accomplished.  The  radial  side  of  the  forearm  is  shortened 
unless  the  ulna  has  been  simultaneously  fractured,  in  which  event  the 
entire  forearm  is  shortened.  Reposition  is  accomplished  by  means  of 
strong  extension,  with  the  elbow  flexed  and  the  forearm  supinated. 

In  all  cases  of  isolated  radial  luxation  the  anular  ligament  is  torn 
or  the  capitulum  is  delivered  out  of  it.  Very  often,  especially  in 
anterior  dislocations,  portions  of  the  capsule  are  incarcerated  and 
reposition   is  not  attainable.     Under  these  circumstances,  the  open 


Fig.  210. —  Kontgexogeam  of  Isolated  Anterior  Dislocatiox  of  the  Head  of 
THE  Eadius.      (Harlem  Hospital  case.) 

operation  is  indicated.  The  seat  of  the  injury  is  readily  approached 
through  an  external  longitudinal  incision.  Anterior  approach  involves 
danger  of  injury  to  the  radial  nerve.  In  old  cases,  resection  of  the 
head  of  the  bone  may  be  demanded. 

IxTRA-ARTicuLAR  INJURIES. — Yarious  articular  injuries  of  the  elbow 
joint  are  grouped  under  the  term  derangement  interne.  One  of  these, 
avulsion  of  the  capitulum  humeri,  has  already  been  described.  An- 
other, the  etiolog}'  and  symptom  complex  of  which  are  not  clearlj^  un- 
,  derstood,  merits  mention  in  this  connection.  The  condition  is  seen  in 
young  children  and  is  caused  by  severe  traction  on  the  arm,  imposed 
hy  the  attendant  in  an  effort  to  obviate  a  fall,  or  when  the  child  is 
lifted  by  the  hand.    The  symptoms  consist  in  helpless  pronation  and 


620     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

pain  without  any  discernible  deformity.  Passive  supination  causes 
great  pain ;  however,  execution  of  supination,  together  with  extension 
and  followed  by  flexion,  causes  the  pathological  picture  to  disappear. 
Usually,  the  child  is  able  to  use  the  hand  at  once,  but  it  is  best  to  im- 
mobilize it  for  a  few  days.  The  symptom  complex  shows  a  tendency 
to  return.  Some  surgeons  consider  that  the  phenomenon  is  caused 
by  an  incoinplete  anterior  luxaiion  of  the  head  of  ilie  radius;  others 
ascribe  it  to  an  incarceration  of  the  posterior  portion  of  the  capsule 
between  the  latter  and  the  humerus. 

Dislocations  of  the  Wrist. —  Luxation  of  the  Radiocarpal  Joint. — 
This  is  exceedingly  rare.  Most  of  the  cases  diagnosticated  as  such  are 
typical  epiph^'seal  separations  of  the  radius.  A  genuine  dislocation  is 
usually  attended  with  fracture  of  the  styloid  process  of  the  radius 
(see  differential  diagnosis  between  fracture  and  dislocation  at  the 
wrist  joint,  p.  726). 

The  luxation  may  be  dorsal  or  volar;  the  carpus  rests  either  on  the 
dorsal  or  volar  side  of  the  articular  ends  of  the  bones  of  the  forearm. 
The  injur}'  is  caused  b}'  a  fall  on  the  hand  in  dorsal  (dorsal  luxation) 
or  in  volar  flexion  (volar  luxation).  The  diagnosis  is  based  on  exact 
palpation  and  on  the  X-raj'  picture.  Reposition,  in  either  instance, 
follows  traction  and  direct  pressure. 

Luxations  in  the  Metacarpal  Joints. —  A  dislocation,  so  that  the 
two  rows  are  displaced,  is  also  very  rare.  Luxation  of  a  single  carpal 
bone  is  not  as  rare.  The  luxated  bone  forms  an  elevation,  the  location 
and  form  of  which  makes  the  diagnosis. 

Luxations  of  the  Carpometacarpal  Joints. — These  are  not  com- 
mon. Dislocation  of  the  carpometacarpal  joint  of  the  thumb  is  most 
frequent ;  it  is  usually  a  dorsal  luxation.  The  abnormal  direction  of 
the  shaft  of  the  metacarpus  indicates  the  diagnosis.  Direct  traction 
accomplishes  reduction. 

Luxations  in  the  Metacarpo-Phalangeal  Articulations. — Dislocations  of 
the  second  to  the  fifth  fingers  are  rare.  Luxation  of  the  thumb  is  more 
frequent  and  of  great  importance. 

The  typical  dislocation  of  the  thumb  (luxatio  pollicis)  is  always 
dorsal,  i.  e.,  the  base  of  the  first  phalanx  rests  on  the  capitulum  of 
the  first  metacarpus.  In  the  incomplete  form,  the  joint  surfaces  are 
in  .slight  contact ;  in  the  complete  form,  they  are  entirely  separated. 

The  malposition  may  be  produced  upon  the  cadaver  by  overextend- 
ing  the  joint  and  making  backward  pressure  on  the  base  of  the 
phalanx;  when  the  thumb  is  erected  the  characteristic  deformity  is 


DISLOCATIONS 


621 


produced.  Helferich-  has  succeeded  in  causing  incarceration  of  soft 
parts  and  irredueibility  of  the  dislocation  in  this  way. 

Fixation  of  the  thumb  is  the  most  striking  feature  of  the  dislocation ; 

this  is  due  to  the 
drag  of  the  soft 
parts  of  the  joint 
and  of  those  sur- 
rounding it.  The 
lateral  ligaments 
are     often     torn 

Fig.   211. —  Faulty  ^NLvxeu^-eb  in  ax  Effort  at  Eeposi-    ^j^j  too-ether  with 
TION  BY  Tkactiox    (buttonholc  mechauism).  '      °    , 

m,  .    ,       .    .  ,  ,  ,  a    n  u  m  b  e  r    o  I 

The  capitulum  is  mearceratea  between  the  tendon  or  the 

flexor  pollicis  which  lies  behind  the  carpal  bone  and  becomes  Strong  musclcs 
visible  below  it,  and  the  flexor  brevis  and  adductor  pollicis  g^^^]  tendons  en- 
muscles.     Traction  only  increases  the  incarceration.  .  ' 

Circle  the  meta- 
carpus. In  this  way  a  sort  of  "reposition  hindrance"  is  created  when 
faulty  methods  of  reduction  are  employed. 

"When  simple  traction  is  made,  the  stronger  the  "pull"  the  more 
firmly  and  closely  the  muscles  grasp  the  neck  of  the  capitulum  and 
interfere  with  reduc- 
tion (Fig.  211). 

S  ympt  o  m  s . — The 
bayonet  outline  of  the 
thumb  in  its  relation 
to  the  first  metacarpus ; 
the  prominence  of  the 
capitulum  metacarpi 
on  the  volar  side ;  the 
evidence  of  the  abnor- 
mal direction  of  the 
first  phalanx;  together 
with  the  rigid  fixation 


Fig.    212. —  Propek    Maxeitver 


Keposition. 


„     -  L-     +Vi  "^^^^  thumb  is  pushed  forward  while  held  in  hyper- 

01  the  parts,  make  tne   extension.     The  manipulation  is  not  unlike  that  em- 


[doyed  in  connection  with  posterior  dislocation  at  the 
elbow  joint. 


diagnosis. 

As  in  all  dislocations 
of  hinge  joints,  reposition  must  be  accomplished  without  force. 

The  THUMB  IS  HYPEREXTEXDED   and  DIRECT  PRESSURE  IS  MADE  AGAINST 
THE  BASE  OF  THE  FIRST  PHALANX,  IN  A  FORWARD  DIRECTION    (Fig.   212). 

As  soon  as  the  greater  part  of  the  two  joint  surfaces  is  in  normal 


622     INJUHIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


contact,  flexion  becomes  possible  and  reduction  is  accomplished.  These 
maneuvers  must  be  carefully  executed ;  however,  despite  these,  reposi- 
tion ma}'  not  be  achieved. 

Incarceration  of  the  capsule  and,  at  times,  of  the  sesamoid  hone 
may  also  be  a  reposition  hindrance.  Helfericlr  found  the  tendon 
of  the  flexor  longus  pollicis  the  cause  of  failure  at  reduction  in  a  num- 
ber of  instances.  The  tendon  snares  the  neck  of  the  first  metacarpus. 
When  the  ulnar  side  of  the  articular  side  of  the  capitulum  ends  in  a 
large  tuberosity,  which  often  occurs,  the  tendon  is  caught  upon  it  and 
reposition  is  impossible.  This  condition  of  affairs  may,  at  times,  be 
recognized  by  the  inclination  of  the  thumb  toward  the  ulnar  side  and 
it  may  be  possible  to  overcome  the 
difficulty  by  bending  the  thumb  in 
that  direction,  though  this  does  not 
by  any  means  always  succeed.  Oc- 
casionally, in  faulty  efforts  at  reposi- 
tion, the  capsule  and  the  outer  sesa- 
moid bone  are  forced  into  the  op- 
posite direction  and  incarcerated  on 
the  opposite  side  (luxatiocomplexa). 

Failure  at  reposition  should  be 
followed  by  immediate  arthrotoniy. 
He.lferich^  states  that  in  his  experi- 
ence exposure  of  the  luxation  at  the 
volar  side  of  the  capitulum  and 
liberation  of  the  incarcerated  tis- 
sues has  resulted  in  reduction  of  the 
dislocation  and  return  of  function  in  every  instance 
section  of  the  capitulum  is  necessary. 

The  description  submitted  above  would  seem  to  make  farther  discus- 
sion as  to  diagnosis  and  treatment  unnecessary. 

The  luxations  of  the  metacarpophalangeal  joints  of  the  second  to 
the  fifth  fingers  are  usually  dorsal.  They  are  also,  at  times,  attended 
with  incarceration  of  the  capsule;  occasionally,  lateral  angulation  is 
also  present.  Reposition  is  accomplished  by  hyperextension  and  for- 
ward pressure. 

Luxations  of  the  Ixterphalangeal  Joints  of  the  Fingers. — Such 
displacements  are  not  rare.  They  are  dorsal  or  volar  or  lateral  (after 
tearing  of  the  lateral  ligaments).  They  occur  in  any  of  the  joints. 
The  diagnosis  and  reposition  present  no  difficulties  (Fig.  213). 


Fig.  213. EONTGENOGRAM  OF  DIS- 
LOCATION OP  Terminal  Phalanx 
OF  Thumb   (Moorhead). 


At  times,  re- 


DISLOCATIONS 


623 


Dislocations  of  the  Hip. — Only  the  application  of  great  force  dis- 
locates the  head  of  the  femur  from  the  acetabulum.  The  provocative 
trauma  is  directed  either  against  the  trunk  or  the  thi^h.    It  is  difficult 


Fig.  214. —  Ischiadic  Luxatiox   (anatomical  preparation). 

The  fibers  of  the  gluteus  maximus  are  held  apart  with  retractors; 
the  minor  muscle  is  visible  above  and  below  the  head  of  the  bone.  The 
pyriformis  presents  below  the  minimus.  The  internal  obturator  lies 
above  the  head  of  the  bone.  The  quadratus  femoris,  which  lies  beneath 
the  obturator  externus,  is  partly  torn.  The  great  sciatic  nerve  is 
shown  lying  internal  to  the  head  of  the  bone.  A  portion  of  the  torn, 
ligameutum  teres  is  attached  to  the  head  of  the  bone;  the  ligament  is 
most  likely  to  be  torn  from  its  bony  attachment. 


to  see  how  force  applied  directly  to  the  trochanter  could  produce  a 
luxation  of  the  hip  joint.  The  posterior  and  the  anterior  forms  are 
the  most  frequent,  the  others  are  rare.  The  mechanism  of  the  luxa- 
tion and  the  factors  entering  into  its  fixation  have  been  cleared  up  by 


624     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

Bigelow^  of  Boston,  who  showed  the  influence  of  the  ileofemoral  liga- 
ment in  this  connection.  In  all  regular  luxations,  this  ligament  is 
preserved,  in  the  irregular  it  is  torn  and  the  clinical  picture  becomes 
atj'pical. 

Posterior  Dislocations. —  {Luxatio  postica,  retrocoiylmdea)  (Fig. 
214). 

When,  on  the  cadaver,  the  flexed  and  slightly  abducted  thigh  is 
rotated  internally,  the  posterior  portion  of  the  capsule  of  the  hip 
joint  is  made  very  tense;  continuation  of  the  motion  causes  the  neck 
of  the  femur  to  impinge  upon  the  anterior  portion  of  the  rim  of  the 
acetabulum,  forming  a  fulcrum;  the  long  arm  of  the  lever  (shaft  of 
the  femur)  acts  very  powerfully  on  the  short  arm  (the  head)  ;  the 
head  is  forced  against  the  capsule;  the  capsule  tears  at  its  posterior 
aspect;  the  head  leaves  the  acetabulum  (tearing  the  ligamentum  teres), 
and  a  posterior  dislocation  is  established. 

The  posterior  dislocations  are  two  in  number;  iliac  and  ischiadic. 
In  the  former  the  head  of  the  femur  rests  on  the  ilium,  in  the  latter 
it  is  lower,  i.  e.,  on  the  upper  edge  of  the  ischium.  The  important 
anatomical  difference  is,  that  in  the  iliac  luxation  the  caput  fcmoris 
lies  above  the  tendon  of  the  obturator  internus;  in  the  ischiadic  it 
lies  below  it.  Experimentally,  the  ischiadic  luxation  is  produced 
when  the  fully  flexed  thigh  is  rotated  inward,  while  the  iliac  occurs 
when  the  thigh  is  only  slightly  flexed. 

In  the  living,  the  posterior  dislocation  is  produced  in  a  similar 
manner,  either  as  a  result  of  a  movement  of  the  limb  (rare)  or  when 
the  pelvis  moves  while  the  thigh  is  fixed  (often).  The  head  of  the 
bone  is  displaced  either  above  or  below  the  obturator  internus ;  how- 
ever, it  may  leave  the  acetabulum  at  its  lower  aspect  and  reach  the 
iliac  position  as  the  outcome  of  secondary  displacement,  where  it  is 
arrested  by  the  iliofemoral  ligament  and  the  external  rotators  (unless 
these  are  torn).  In  the  latter  event,  the  head  of  the  bone  may  lie 
behind  the  obturator  internus  muscle,  i.  e.,  this  muscle  and  the 
gemelli  lie  between  the  caput  and  the  acetabulum ;  a  serious  hindrance 
to  reposition. 

Symptoms. — In  backward  dislocations,  the  thigh  is  rotated  inward, 
is  more  or  less  flexed  and  fixed  in  elastic  abduction.  This  condition 
of  affairs  is  easily  recognized  by  inspection,  as  the  patient  lies  on  his 
back,  as  is  also  shortening  of  the  luxated  limb,  which  is  greater  in 
the  iliac  than  in  the  ischiadic  form  of  dislocation.  Shortening  is  also 
measurable  when  the  distances  from  the  anterior  spine  of  the  ilium 


DISLOCATIONS 


625 


to  the  lower  end  of  the- patellae  of  the  two  sides  are  compared.  For  the 
purpose  the  limbs  should  be  symmetricallj'  postured.  Shortening  is 
grossly  manifest  when  both  thighs  are  held  in  horizontal  flexion,  though 
the  postures  of  the  limbs  must  be  symmetrical  and  the  pelvis  be  held 
rigid.  This  observation  is  easily  made  when  the  patient  is  narcotized. 
The  displacement  may  also  be  verified  by  measurements  made  in  the 
region  of  the  hip.    Normally,  a  line  carried  from  the  anterior  superior 

spine  of  the  ilium  to 
the  tuberosity  of  the 
ischium  with  the 
thigh  flexed,  crosses 
the  tip  of  the  troch- 
anter major.  This  is 
called  the  Boser- 
Nelaton  line  (Fig. 
215).  In  backward 
luxations  the  upper 
end  of  the  femur  is 
displaced  upward, 
and  the  trochanter 
is  above  the  line. 
The  observation  is 
made  with  the  pa- 
tient h'ing  on  the 
sound  side  and  is 
indicative  of  the  lo- 
cation of  the  head  of 
the  bone  when  there 
is  no  fracture. 

The  inivard  rota- 
tion of  the  limh  is 
also  brought  out  in 
this  way;  normally, 
the  trochanter  corresponds  to  the  center  of  the  Roser-Nelaton  line  when 
the  limb  is  placed  midway  between  inversion  and  eversion.  Displace- 
ment of  the  trochanter  anteriorly  indicates  inversion  of  the  femur 
which  is  always  present  in  posterior  luxations. 

Palpation  of  the  region  of  the  hip,  with  the  patient  lying  on  his 
back,  reveals  gross  malposition  of  the  bone.     The  distance  between 


Fig.    215.— a. 


The     EOSER-XIELATON 

Hip  Flexed. 


Line    with    the 


626     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


the  anterior  spines  and  the  tips  of  the  trochanters  may  be  recognized 
with  the  fingers. 

Palpation  of  the  head  of  the  femur  in  its  abnormal  position  is  pos- 
sible, but  is  made  difficult  by  the  great  thickness  of  the  interposing 
gluteus  maximus  muscle.  Efforts  in  this  connection  should  be  made 
with  the  patient  narcotized. 

Active  motio7i  is  entirely  abolished.  Passive  flexion  and  a  slight 
increase  in  the  path- 
ological condition, 
i.  e.,  abduction  and 
internal  rotation,  is 
possible  but  causes 
severe  pain.  Efforts 
to  abduct  and  rotate 
the  limb  outward 
demonstrate  the 
elastic  resistance  of 
the  tense  ligament 
of  Bigelow  (or  Ber- 
tini).  Free  passive 
motility  and  greatly 
restricted  internal 
rotation  means  ex- 
tensive tearing  of 
the  capsule  and  mus- 
culature. Great 
elastic  resistance  in- 
dicates a  small  tear 
in  the  capsule  and 
relatively  slight  lac- 
eration of  muscles. 

Treatment. —  (Fig. 
216).  The  employment  of  narcosis  is  imperative.  This  is  also  advis- 
able for  the  purpose  of  mtaking  the  diagnosis,  which  is  at  once  fol- 
lowed by  reposition.  The  patient  should  be  placed  upon  the 
floor  (on  a  blanket).  The  injured  extremity  is  elevated  so  that 
the  thigh  is  perpendicular  and  the  knee  flexed  at  right  angles  to  the 
thigh.  An  assistant,  who  kneels  on  the  floor,  steadies  the  pelvis.  At 
times  (when  the  head  of  the  bone  rests  near  the  posterior  edge  of  the 


B 

Fig.  215. —  B,  Skeletal  Eepbesentation  of  A. 


DISLOCATIONS 


627 


acetabulum),  simple  traction  directly  upward  accomplishes  the  repo- 
sition. When  the  head  of  the  bone  is  some  distance  from  the  acetab- 
ulum, simple  traction  may  cause  it  to  impinge  against  its  posterior 
edge,  so  that  abduction  which,  a  priori,  is  helpful  in  reduction,  now 
causes  the  bone  to  be  still  more  tightl}^  wedged  against  the  rim  of 
the  cavity.  This  explains  the  rationale  of  carrying  the  thigh  into 
abduction,  which  also  carries  the  bone  over  the  rim,  in  order  to  ac- 
complish reposition  in  this  class  of  cases.  To  summarize :  Reposition 
follows  traction  in  abduction  with  some  rotation  inward;  when  this 
fails,  traction  is  made  in  abduction  with  outward  rotation;  in  this, 
however,  there  is  danger  that  the  head  of  the  bone  will  miss  the 
acetabulum  and  slip  to  the  anterior  aspect  of  the  joint  (so-called  cir- 
cumduction). As  a 
secondary  displacement 
of  this  sort  is  liable  to 
happen  at  any  time,  the 
position  of  the  head  of 
the  bone  does  not  neces- 
sarily indicate  the  loca- 
tion of  the  tear  in  the 
capsule.  The  latter  may 
be  torn  in  a  longitudinal 
or  transverse  direction, 
and  this  may  be  in- 
creased by  manipula- 
tions. It  is,  at  times,  a 
hindrance  to  reposition, 
which  can  be  removed 
only  b}'  the  open  operation.  Helferich^  has  succeeded  in  reposition 
after  exposure  of  the  joint  in  cases  in  which  the  luxation  has  been  of 
several  months'  standing.  In  very  old  cases,  resection  of  the  head  of 
the  bone  (arthrectomy)  improves  the  motility  of  the  joint,  while  sub- 
trochanteric osteotomy  places  the  limb  in  a  position  of  usefulness. 

Anterior  Dislocations  {Luxatio  aniica,  precotyloidea). —  Anterior 
luxations  do  not  occur  as  frequently  as  the  posterior. 

Anterior  luxation  may  be  produced  experimentally  by  abduction 
and  outward  rotation.  The  anterior  portion  of  the  capsule  tears  at 
its  upper  aspect  and  the  head  of  the  bone  rests  on  the  pubes  (luxatio 
suprapubica)  ;    when  the  leg  is  hyperextended,  the  capsule  is  torn 


Fig.  216. —  Reduction  of  a  Dislocated  Hip. 

The   patient   lies   on   the   floor    (nareotized)  ;    the 
thiyh  and  Icsr  are  flexed  at  right  angles. 


628     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

lower   down   and   an   infrapubic   luxation    (luxatio   infrapubica)    is 
created. 

On  the  living,  anterior  dislocations  are  produced  in  a  similar  manner 
or  by  force  directed  against  the  pelvis  when  the  limb  is  fixed. 


A  a 

A  and  a,  Ischiatic  Dislocations. 


B  and  b,  Iliac  Luxation. 
Fig.  217. —  Dislocations  at  the  Hip. 


DISLOCATIONS 


629 


In  all  anterior  dislocations  the  extremity  is  rotated  ouiicard  and 
ahdiicted.  The  degree  of  flexion  varies;  in  suprapubic  dislocations 
it  is  slight  and,  at  times,  extension  occurs ;  in  the  infrapubic  form  it 


C  and  c,  Obtubatob  Luxation. 


D  d 

D  and  d,  Suprapttbic  Luxation. 

Fig.  217. —  Dislocations  at  the  Hip. 


630     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


is  present  and  is  greater  the  farther  the  head  of  the  bone  is  dis- 
placed forward  (caused  by  tension  of  the  iliofemoral  ligament). 

In  suprapuMc  luxations  the  caput  femoris  may  be  palpated  in  the 
inguinal  region;  it  is  close  to  the  rim  of  the  acetabulum  (linea  pec- 
tinea)  or  lies  on  the  pubis  (pubic  line)  or  beneath  the  anterior  in- 
ferior spine  of  the  ilium  (subspinous  or  iliopubic  line).  At  times, 
the  femoral  artery  is  lifted  by  the  caput;  the  patient  complains  of 
pain  in  the  sciatic  nerve;  however,  he  is,  not  infrequently,  able  to 
lean  on  the  injured  limb. 

In  infrapuhic  luxa- 
tions external  rota- 
tion and  abduction 
and  flexion  are  clearly 
defined.  They  are 
subdivided  into  ob- 
turator, when  the 
caput  femoris  lies  in 
the  region  of  the  ob- 
turator foramen,  and 
the  very  rare  perineal, 
when  the  caput  lies 
in  contact  with  the 
ascending  ramus  of 
the  ischium.  In  ol)- 
turator  luxations  the 
caput  is  buried  in  the 
depths  of  the  opening 
and  is  not  easily  pal- 
pated the  trochanter  Fig.  218. —  Eontgenogram  of  Iliac  Luxation  at  the 
,  ,'.  1-1  Hip  Joint    (Harlem  Hospital  case). 

has  disappeared   and 

the  limb  is  held  in  elastic  fixation. 

In  making  the  diagnosis,  fracture  of  the  neck  of  the  femur  must  be 
excluded.  Although  the  leg  is  everted  and  shortened  the  characteristic 
elastic  fixation  is  absent  and  the  limb  can  be  moved  in  all  directions, 
but  always  returns  again  to  helpless  aversion. 

In  reduction  it  may  be  necessary  to  hyperextend  the  thigh  and 
employ  traction  in  order  to  bring  the  caput  femoris  closer  to  the 
acetabulum;  this  is  done  with  the  patient  lying  on  a  table.  The 
other  steps  in  the  reduction  are  carried  on  with  the  patient  lying 


DISLOCATIONS 


631 


on  the  floor.  Narcosis  is  essential.  Flexion  of  the  thigh  and  inward 
rotation  usually  accomplish  reposition.  Circumduction  of  the  head 
of  the  bone  is  prevented  by  maintaining  traction  during  the  manipu- 
lations. 

Rare  Dislocations  op  the  Hip. — Downward  dislocation  (luxatio 
infracotyloidea).  This  variety  is  very  rare.  The  caput  femoris  lies 
below  the  acetabulum,  the  limb  is  elongated,  marked  flexion  is  always 
absent,  slight  abduction  is  present  and  rotation  uncertain.  It  is 
caused  by  forcible  abduction.     In  not  a  few  of  the  cases  the  patient 

is  able  to  bear  some  weight 
on  the  limb.  Reposition  is 
accomplished  by  traction 
upon  the  flexed  thigh. 

Upward  dislocation 
(luxatio  supracotyloidea) 
is  also  rare.  The  caput 
femoris  lies  at  the  anterior 
inferior  spine  and  is  di- 
rectly palpable.  The  ex- 
tremity is  extended,  slightly 
rotated  outward,  and  ab- 
ducted and  shortened.  Re- 
position by  flexion  and  in- 
ward rotation. 

To    the   irregular    luxa- 
tMons  may  be  added  those 
occurring  in  connection  with  fracture  of  the  femur  (neck  and  region 
of  the  trochanter)  or  of  the  pelvis  (rim  of  the  acetabulum,  etc.). 

Luxatio  centralis  is  a  term  applied  to  an  exceedingly  rare  dislo- 
cation in  which  the  head  of  the  femur  is  forced  into  the  pelvis  through 
the  comminuted  acetabulum.  The  injury  is  analogous  to  fracture  of 
the  skull  by  impact  on  the  part  of  the  lower  jaw.  Reduction  of  the 
deformity  may  be  attained  by  traction  in  semiflexion  with  additional 
lateral  traction  upon  the  upper  portion  of  the  thigh. 

Dislocation  of  the  Knee  Joint. — Intra-articular  injuries  of  the  liga- 
ments of  the  knee  joint  are  more  frequent  than  actual  dislocations  of 
the  joint,  which  latter  are  only  one  per  cent  of  the  total  number  of 
luxations.  Dislocations  in  this  situation  are  divided  into :  Anterior 
(luxatio  genu  antica),  which  is  attended  with  tearing  of  the  lateral 
and  crucial  ligaments;  posterior  (luxatio  genu  postica),  which  is  more 


219 


220 


Fig. 


219. —  Phantom   of  Forward  Disloca- 
tion OF  Leg. 


Fig.    220. —  Phantom    of   Backward   Dislo- 
cation OF  Leg. 


632     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


an  anterior  dislocation  of  tlie  condj'les  of  the 
femur;  and  lateral  (luxatio  genu  lateralis),  in 
which    the    leg    is    in    an    abducted    or    adducted 

To  these  may  be  added  the 
incomplete  luxations  occurring 
in  various  directions.  In  all 
cases  the  condyles  are  more  or 
less  palpable  in  their  abnormal 
positions.  As  the  production 
of  dislocations  in  this  region 
is  attended  with  the  applica-* 
tion  of  great  force,  they  are 
ver}^  likely  to  be  complicated 
by  severe  injuries  to  soft  parts 
of  which  compound  luxation  is 
not  the  least  frequent.  Pri- 
mary lesions  of  the  popliteal 
vessels  and  pressure  on  these 
vessels,  when  the  luxation  is 
not  promptly  reduced,  may  re- 
sult in  gangrene  of  the  leg. 
Reposition  is  easy  and  is  at- 
tained by  traction  and  direct 
pressure. 

Dislocations  of  the  Patella. — 
Despite  the  fact  that  the  patella 
is  not  strongly  fixed  and  is 
really  only  a  sesamoid  bone 
located  between  the  ligamen- 
tum  patellae  and  the  quad- 
riceps, it  is  rarely  luxated. 

Outward  Luxation. — Out- 
ward dislocation  is  the  most 
frequent  form  of  luxation  ;  this 
is  favored  by  the  location  of 
the  patella,  which  is  more  in 

Fig.  221. —  A,  Outward  Dislocation  of  Patella.  B,  Preparation  of  A.  C,  In- 
ward Vertical  Dislocation  of  Patella  Viewed  from  Inner  Side 'cIf  Limb. 
D,  Complete  Rotation  of  Patella. 

The  leg  is  strongly  flexed.     The  outline  of  the  patella  is  visible. 


DISLOCATIONS 


633 


contact  with  the  external  condyle  than  with  the  internal,  espec- 
ially when  the  knee  is  in  a  valgus  position.  The  luxation  is  in- 
complete when  the  articular  surface  of  the  patella  remains  in  contact 
with  that  of  the  condyle ;  it  is  complete  when  it  rests  on  the  side  of  the 
external  condyle.  The  luxation  may  be  produced  when  the  knee  is 
extended  or  flexed ;  in  the  former,  the  patella  slips  directly  outward 
over  the  anterior  surface  of  the  lower  edge  of  the  femur  (may  happen 
by  muscular  exertion  on  part  of  the  quadriceps  extensor  with  the 
knee  extended)  ;  otherwise,  the  patella  slips  into  the  space  between 
the  external  condyle  and  the  tibia;  this  is  usually  caused  by  direct 
violence  from  in  front,  such  as  a  blow  directed  against  the  knee  of  a 

horseman.  Reposition  is  readily  ac- 
complished by  direct  pressure;  the 
knee  must  be  extended  and  the 
quadriceps  muscle  relaxed  by  flex- 
ing the  thigh  on  the  pelvis. 

Habitual  Dislocation. —  Habit- 
ual luxation  of  the  patella  follows 
trauma.  The  condition  may  be 
obviated  by  the  use  of  an  apparatus 
such  as  is  shown  in  Fig.  222.  In 
frequently  recurring  luxations, 
osteotomy  at  the  lower  end  of  the 
femur  or  shortening  of  the  inner 
side  of  the  capsule  may  be  em- 
ploj'ed  (Part  IV,  chap.  vi). 

Vertical  Luxation. —  A  vertical 
dislocation  of  the  patella  occurs 
when  the  patella  is  rotated  90°,  so 
that  its  edge  lies  in  the  groove  between  the  two  condyles  of  the  femur. 
The  articular  surface  of  the  luxated  bone  may  be  turned  toward  the 
inner  or  outer  side  of  the  joint ;  the  former  is  the  more  frequent.  The 
condition  is  caused  by  direct  force  from  in  front  or  from  the  side,  and 
is  believed,  in  rare  instances,  to  be  the  result  of  violent  muscular  action. 
The  position  of  the  patella  is  readily  made  out  when  the  knee  is  extended. 
In  complete  rotation,  the  patella  is  turned  180° ;  an  increase  in  the 
rotation  occurring  in  connection  with  the  vertical  luxation.  The 
articular  surface  of  the  rotated  bone  faces  forward.  The  condition  is 
exceedingly  rare.  The  diagnosis  is  difficult  and  is  arrived  at  only 
when  exact  palpation  is  made. 


Fig.  222. —  Apparatus  for  Control 
OF  Habitual  Luxation  of  the 
Patella. 


634     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Dislocations  of  the  Ankle  Joint. — Flexion  and  extension  of  the  foot 
occur  in  the  talocrural  joint,  pronation  and  supination  in  the  medio- 
tarsal  articulation.  In  the  latter  instance,  the  talus  remains  quietly 
connected  with  the 
tibia  and  fibula, 
while  motion  takes 
place  in  the  articula- 
tions between  the 
talus  and  the  cal- 
caneum  on  the  one 
hand  and  with  the 
navicularis  on  the 
other. 

The  force  con- 
cerned in  producing 
luxations  and  avul- 
sion fractures  in- 
jures the  parts  by 
exaggerating  the 
normal  excursions  of 
the  foot  as  follows : 

1.  Movements  of 
the  foot  in  a  fronto- 
horizontal  axis  in 
tlexion  (plantar 
flexion)  or  extension 
(dorsal  flexion). 

2.  In  a  sagitto- 
horizontal  (antero- 
posterior) axis  car- 
ried through  the 
long  diameter  of  the 
foot ;  the  movements 
being,    pronation 


Jk  i ' 

^1       ^Ib^ 

lllfci^ 

^ 

Fig.  223. —  Dislocation  of  the  Foot  in  the  Talo- 
crural Joint. 


,„      .  „   ,,       „     ,        A,  Backward  luxation  of  the  foot:  B,  forward  luxa- 

(flexion  of  the  foot  tion  of  foot. 

toward  the  fibula), 

or  supination  (flexion  toward  the  tibia).     These  movements  are  often 

der'gnated  as  abduction  or  adduction. 

3.     Around  the  long  axis  perpendicular  with  that  of  the  leg  and 


DISLOCATIONS  635 

carried  in  the  long  axis  of  the  foot  so  that  rotation  of  the  foot  outward 
(point  of  the  foot  outward) — abduction — or  inward  (point  of  the 
foot  inward) — adduction — follows. 

Dislocation  of  the  Talocrural  Joint  {Fig.  223). —  The  actual 
luxations  of  the  foot  are  anterior  (produced  by  exaggerated  dorsal 
flexion)  and  posterior  (by  excessive  plantar  flexion).  The  positions 
of  the  foot  make  the  dingnosis.  Reposition  follows  direct  backward  or 
forward  pressure  on  the  tibia  with  simultaneous  flexion  in  the  direction 
which  produced  the  luxation.  Lateral  luxations  without  fracture  are 
not  possible. 

Talotarsal  Dislocations. — Dislocations  of  the  talotarsal  joint  or, 
so-called,  luxatio  sub  talo,  may  be  outward,  from  excessive  pronation; 
inward  from  forcible  supination  of  the  foot ;  and  often  occur  in  con- 
nection with  other  injuries.  Both  luxations  are  rare.  The  diagnosis 
is  difficult.  Exact  palpation  of  the  bony  prominences,  under  narcosis, 
and  the  X-ray  are  necessary.  Reposition  is  difficult  and  may  require 
the  open  operation. 

Dislocations  of  the  Talus. — Isolated  dislocations  of  the  talus 
(luxatio  tali)  occur  in  all  directions.  The  mechanism  of  their  pro- 
duction is  not  clear.  The  deformity  is  severe.  The  tibia  is  nearer  the 
sole  of  the  foot  than  it  is  normally,  and,  at  times,  articulates  directly 
with  the  caleaneum. 

Reposition  is  very  difficult  and  often  demands  the  open  operation. 

SuBASTRAGALOiD  DISLOCATIONS. — In  thcsc  cascs  the  X-ray  picture  is 
invaluable.  This  should  not  be  delayed,  as  swelling  disappears  very 
slowl}^  and  reposition  must  be  accomplished  soon. 

The  injury  is  more  frequent  than  has  been  previousl}^  assumed. 
The,  so-called,  luxatio  pedis  sub  talo  (subastragaloid  dislocation)  is 
the  most  frequent;  luxation  in  Chopart's  joint,  the,  so-called,  luxatio 
mediotarsa,  is  very  rare.  Dislocations  of  a  single  or  of  several  tarsal 
bones  in  combination  are  mostly  subluxations.  The  diagnosis  is 
usually  made  with  the  X-ra}'.  Reposition  may  be  very  difficult  and 
is  often  not  accomplished  until  the  injury  is  exposed.  It  may  be 
necessary  to  fix  the  dissociated  parts  by  means  of  suture,  nails,  etc., 
and  in  some  instances,  partial  or  complete  resection  of  the  luxated 
bone  or  bones  is  indicated. 

Metatarsal  Dislocation. —  In  luxation  of  the  metatarsal  bones, 
i.  e.,  of  the,  so-called,  LLsfranc  joint,  several  or  all  of  the  metatarsi 
are  dislocated  upon  the  dorsum,  of  the  foot.  An  abnormal  bony  pro- 
trusion is  found  on  the  dorsum  of  the  foot,  which  shows  the  form  of  a 


636     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

pes  excavitus.  Plantar  luxation  is  very  rare,  the  lateral  is  not  uncom- 
mon. Reposition  is  difficult,  each  bone  being  reduced  separately 
The  effort  may  succeed  in  fresh  cases,  though  usually  open  reduction 
is  necessary. 

Dislocation  of  the  Phalanges. —  Dislocations  of  the  toes  are  anal- 
ogous to  those  of  the  fingers  but  are  less  frecjuently  seen.  The  diag- 
nosis is  easy.  Reposition  is  accomplished  by  pressure  on  the  dorsal 
phalanx. 

Vertebral  Dislocations.— Dislocations  of  the  vertebrae  are  taken  up 
with  fractures  in  this  situation  (p.  679). 

OPEN  INJURIES  OF  JOINTS 

Wounds  of  all  kinds  may  penetrate  the  capsule  of  a  joint.  The 
entrance  of  foreign  bodies  into  joints  (projectiles,  needles,  nails,  pieces 
of  metal  and  wood,  fragments  of  stone,  etc.)  are  not  uncommon. 

The  symptoms  and  the  clinical  course  of  joint  injuries  are  deter- 
mined by  the  development  of  infection.  The  latter  is  attended  with 
great  danger  and  presents  one  of  the  complex  problems  of  surgery. 

Foreign  bodies  usually  cause  small  openings  in  the  joint  capsule, 
the  involvement  of  which  is  an  important  factor  in  cases  of  this  sort. 
The  spontaneous  discharge  of  synovial  fluid  makes  the  diagnosis  cer- 
tain ;  however,  a  small  opening  in  the  capsule  may  be  closed  by  a  blood 
clot  or  covered  by  the  modification  of  relationship  of  the  parts  to  each 
other  as  the  result  of  changes  of  posture  of  the  limb,  so  that  the  fluid 
is  retained.  The  use  of  the  prohe  for  diagnostic  purposes  is  not  per- 
ynissihle  in  these  cases. 

Moderate  swelling  of  the  joint  immediately^  after  receipt  of  the  in- 
jury, especially  in  cases  of  gunshot  wounds  involving  the  bone,  sug- 
gests effusion  of  blood.  When  the  joint  swells  at  the  end  of  a  day  or 
two,  the  presence  of  infection  may  be  assumed.  In  these  cases,  the 
symptoms  of  local  inflammation  and  the  systemic  disturhances  are 
very  severe. 

Thorough  cleansing  of  the  surface  contiguous  to  small  perforating 
wounds  of  joints,  the  application  of  a  sterile  protective  dressing  and 
immobilization  of  the  part  for  a  few  weeks  is  usually  followed  by 
complete  repair,  even  when  the  capsule  is  penetrated  by  a  foreign 
body.  Attention  was  called  to  the  value  of  a  policy  of  noninterference 
in  cases  of  gunshot  wound  by  the  work  of  v.  Bergmann,*  who  reported 
the  results  of  this  method  in  the  Russo-Turkish  War.  In  cases  of 
moderate  inflammatory  effusion,  aspiration  may  be  employed.   When 


DISLOCATIONS  637 

pus  is  formed,  incision  and  drainage  are  indicated.  In  severe  menac- 
ing- purulent  or  putrefactive  infections,  the  joint  must  be  icidehj 
opened,  resected  or  amputated  according  to  the  indications  (see  Puru- 
lent Arthritis,  p.  311). 

Penetrating  foreign  hodies  with  rough  surfaces  (splinters  of  wood, 
nails,  etc.),  which  frequently  carry  infection  into  the  joint,  should  be 
removed  at  once.  When  healing  occurs  with  a  foreign  body  in  situ 
and  the  joint  is  maintained  in  a  state  of  chronic  irritation,  the  offend- 
ing substance  should  be  removed.  The  exact  location  of  the  foreign 
body  must  be  determined  by  palpation  or  the  X-ray  and  its  removal 
accomplished  with  a  minimum  of  trauma  to  the  joint  structure.  After 
the  operative  procedure  the  joint  should  be  immobilized  for  two  weeks. 

Gaping  "Wounds. — Widely  gaping  wounds  of  joints  are  produced  by 
cutting  instruments  such  as  a  knife,  saber,  scythe,  etc.,  or  may  be  the 
result  of  crushing  or  laceration  of  the  tissues  by  grenade  splinters, 
explosions,  machinery,  and  the  bites  of  large  animals. 

Of  these,  the  incised  wounds  are  the  least  likely  to  be  followed  by 
infection.  In  fresh  cases  the  wound  in  the  capsule  and  the  skin 
wound  may  be  closed  by  suture.  In  older  cases  it  is  best  to  employ 
tamponade  for  a  few  days,  followed  by  secondary  suture  when  the 
danger  of  infection  is  over. 

Contused  and  Lacerated  Wounds. — Contused  and  lacerated  wounds  of 
joints  may  occur  in  connection  with  dislocations.  These  compound 
dislocations  are  the  result  of  great  violence  and  are  usually  attended 
with  extensive  lacerations  of  the  joint  capsule  and  other  contiguous 
soft  parts.  Often  the  articular  surface  of  a  bone  protrudes  through 
the  skin  and  the  tendons,  muscles,  nerves,  and  blood  vessels  are  also 
injured. 

Treatment. — The  treatment  is  based  on  the  general  principles  of 
wound  repair,  together  with  reduction  of  the  dislocation.  Extensive 
contused  and  lacerated  wounds  are  best  treated  with  loose  tamponade 
and  immobilization  of  the  part  in  a  manner  which  permits  of  frequent 
changes  of  dressing. 

In  favorable  cases  healing  occurs,  but  is  usually  followed  by  con- 
siderable impairment  of  function.  Infection  occurs  very  often  and  is 
treated  by  incision,  resection  or  amputation.  Extensive  trauma  to  the 
soft  parts  frequently  results  in  necrosis. 

BIBLIOGRAPHY 

1.  Lexer.  .  Beitr.  z.  klin.  Chir.  Bd.  70,  1910. 

2.  Helfericii.     Atlas  d.  traum.  Fraet.,  etc.,  Miinch.,  1914. 

3.  BiGELOW.     Quoted  by  Helfericii,  No.  2. 

4.  v.  Bergmaxx.     Stuttgart,  1878. 


CHAPTER  IV 

INJUEIES    TO    THE   OSSEOUS    SYSTEM 

SUBCUTANEOUS  INJURIES  OF  BONES  AND  CARTILAGES 

The  effect  of  direct  or  indirect  violence  upon  bone  is  dependent  upon 
its  degree  and  the  character  of  trauma.  An  injury  may  be  so  slight 
as  to  cause  a  simple  effusion  of  blood  beneath  the  periosteum. 

A  subperiosteal  hematoma  is  caused  by  contusion  or  laceration  of 
the  periosteum  which  may  be  coincident  to  injuries  of  the  soft  parts 
or  may  occur  in  connection  with  muscular  contractions.  The  effusion 
results  from  the  tearing  of  blood  vessels  which  enter  the  bone  from 
the  periosteum.  The  subperiosteal  accumulation  of  blood  produces  a 
circumscribed,  painful,  fluctuating  swelling  connected  with  the  bone 
or  with  cartilage.  Hematomata  of  this  sort  occur  upon  the  heads  of 
7iewly  horn  infants  (cephalhematoma)  usually  over  the  parietal  bones 
and  are  due  to  the  displacement  of  the  scalp  which  tears  the  periosteal 
blood  vessels  during  birth.  A  similar  condition,  at  times,  follows 
injury  to  the  ear  in  which  the  perichondrium  is  separated  from  the 
cartilage. 

The  effused  blood  remains  fluid  and  is  absorbed  A'ery  slowly.  In 
some  instances  the  proliferation  of  the  periosteum  forms  a  bony  ring 
at  the  edge  of  the  hematoma  or  the  entire  separated  portion  forms  a 
tliin  bony  wall.  In  certain  situations,  such  as  the  crest  of  the  tibia, 
moderate  trauma  may  be  followed  by  the  formation  of  persistent 
areas  of  bony  thickening. 

Effusions  of  this  sort  may  be  treated  by  moderate  compression  which 
is  sufficient  to  cause  absorption  when  the  effusion  of  blood  is  not  great. 
In  cases  of  extensive  hematoma,  aspiration  or  even  incision  may  be 
necessary. 

Punctate  hemorrhages  into  the  hone  marrow  are  often  the  result  of 
concussion  and  occur  in  connection  with  all  fracturts  or  may  result 
from  violence  which  is  not  sufficient  to  either  fracture  the  bone  or 
produce  a  distinct  hematoma.    Their  significance  lies  in  the  fact  that 

638 


INJURIES  TO  THE  OSSEOUS  SYSTEM  639 

foci  of  this  sort  form  a  favorable  nidus  for  the  development  of  infec- 
tion and  may  be  the  indirect  cause  of  osteomyelitis. 

In  ike  spongiosa,  hemorrhagic  foci  and  destruction  of  the  lamellas 
may  be  followed  by  deformation  of  the  bone,  a  condition  which  occurs 
in  the  neck  of  the  femur  and  in  the  bodies  of  the  vertebrae. 

The  traumatized  areas  are  the  seat  of  granulation  tissue  prolifera- 
tion {sclerotic  osteitis)  or  may  become  modified  (rarefying  osteitis). 

Fractures. — A  Fracture  may  be  defined  as  a  sudden  solution  op 
CONTINUITY  OF  BONE  OR  CARTILAGE,  which  may  be  complete  or  incom- 
plete. To  the  latter  class  belong  fissures  and  infractions.  A  simple 
characterization  of  the  former  is  "a  broken  bone." 

Fractures  may  be  further  divided  into  those  of  traumatic  origin 
and  the  pathological  or  spontaneous  kind  (due  to  suppuration,  tuber- 
culosis, syphilis,  sarcomata,  carcinomata,  enchondromata,  etc.).  A 
bone  which  has  undergone  pathological  changes  would,  of  course,  be 
likely  to  fracture  when  subjected  to  moderate  trauma.  Among  the 
pathological  conditions  favoring  fracture  are  rachitis,  osteomalacia, 
scorbutus,  atrophy  from  parah'sis,  tabes  and  syringomyelia. 

Varieties. — A  fissured  fracture  consists  of  a  crack  or  a  split  in  a 
bone  which  radiates  from  a  complete  fracture,  or  it  may  occur  alone. 
Its  distinctive  characteristic  is  that  while  it  represents  a  solution  of 
continuity  of  bone,  it  does  not  alter  its  outline  nor  cause  a  separation 
of  the  bone  into  fragments.  In  cases  of  fissured  fracture,  the  peri- 
osteum may  or  may  not  be  torn,  so  that  a  palpable  hematoma  is  not 
always  formed.  As  a  rule  the  condition  is  recognized  only  upon  X-ray 
examination. 

An  infraction,  or  "green  stick"  fracture,  involves  only  a  part  of 
the  thickness  of  the  bone  combined  with  a  bending  of  the  rest  of  its 
diameter  at  the  seat  of  the  solution  of  continuity.  Injuries  of  this 
sort  occur  in  the  costal  cartilages  and  are  common  in  the  soft  bones 
of  children  (especially  in  the  rachitic).  The  periosteum  may  or  may 
not  be  torn  at  the  site  of  the  bend,  while  on  the  concave  side  it  remains 
intact. 

Complete  fractures  result  from  violence  which  exceeds  the  limit  of 
the  elasticity  and  the  resistance  of  the  bone.  The  provocative  factor 
may  be  the  sudden  contraction  of  muscles,  the  tension  of  ligaments, 
or  the  action  of  direct  or  indirect  force.  The  fracture  may  occur  at 
the  point  where  the  force  is  received  or  at  a  distance  from  it,  i.  e., 
the  collar  bone  may  be  broken  by  a  fall  upon  the  hand  or  the  occipital 
bone  by  a  fall  upon  the  buttocks. 


640     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  force  which  produces  a  fracture  may  overcome  the  elasticity 
and  the  resistance  of  a  bone  by  heiiding  (bending  fracture),  by 
twisting  (torsion  fracture),  by  pressure  (compression  fracture),  or 
by  tearing  (tearing-  fracture).  Compression  of  a  bone  in  its  long 
diameter  may  cause  it  to  break  at  the  point  of  its  least  resistance. 
The  resistance  which  the  different  bones  of  the  bod^^  offer  to  violence 
varies  widely. 

Forms  of  Fracture. — The  form  a  fracture  takes  depends  upon  the 
direction  and  character  of  the  force  producing  it.  From  this  view- 
point fractures  may  be  divided  into  transverse,  oblique,  longitudinal, 
spiral,  T,  V,  or  Y  shaped,  splintered,  dentate,  and  comminuted;  or, 
basing  the  terminology  upon  the  seat  of  the  facture,  into  fracture  of 
the  shaft  of  the  hone,  separation  of  the  epiphyses,  and  intra-articular 
or  articular. 

Basing  a  classification  upon  the  mechanism  of  production,  the  fol- 
lowing subdivisions  may  be  made  (Helferich^)  : 

A  lending  fracture  may  be  the  result  of  direct  or  indirect  violence. 
If  the  force  acts  at  right  angles  to  the  long  axis  of  the  bone,  the 
fracture  ensues  in  much  the  same  way  as  a  stick  treaks  when  hent 
over  the  knee.  If  the  force  acts  in  the  direction  of  the  long  axis  of 
the  bone,  the  natural  curves  of  the  bone  are  increased  beyond  the  limit 
of  their  elasticity  (neck  of  the  femur),  and  the  solution  of  continuity 
takes  place  at  that  point.  At  times  the  twisting  force  that  results  in 
a  fracture  causes  the  separation  of  a  wedge  shaped  fragment  at  the 
site  of  the  break,  the  base  of  the  wedge  always  corresponding  to  the 
concavity  of  the  bend.  "When  the  wedge  is  not  entirely  separated  the 
fracture  is  oblique,  and  an  oblique  fissure  extends  into  one  of  the  frag- 
ments. Bending  fractures  are  attended  with  the  formation  of  atypical 
fissures  which  radiate  in  various  directions. 

Flexion  fractures  are  closely  related  to  those  caused  by  a  bending 
force.  They  are  produced  b}^  fixing  one  end  of  the  bone  while  the 
other  is  forcibly  moved.  The  mechanism  of  their  production  is  cm- 
ployed  in  the  correction  of  deformities  w'hen  it  is  desirable  to  fracture 
a  bone  at  a  certain  point  (osteoclasis). 

Compression,  or  crushing  fractures,  occur  in  long  tubular  bones  as 
the  result  of  force  directed  in  the  long  axis  of  the  bone  and  are  pro- 
duced by  violence  acting  on  both  of  its  ends.  In  this  way  the  diaph}- 
sis  is  impacted  into  the  spongiosa  of  the  metaphysis  and  the  epiphysis. 
This  form  of  fracture  is  seen  when  the  trochanter  is  forced  into  the 
neck  of  the  femur  and  is  not  uncommon  at  the  upper  end  of  the 


INJURIES  TO  THE  OSSEOUS  SYSTEM 


641 


humerus  and  at  the  upper  portion  of  the  tibia.  Impaction  of  the 
bodies  of  contiguous  vertebrae  and  crusliing  of  the  os  calcLs  occur 
as  the  result  of  a  fall  from  a  considerable  height. 

Tearing  fractures  occur  in  connection  with  injury   of  joints  in 
which  projections  of  hone  are  torji  off,  when  articular  surfaces  are 


Fig.  224. —  Bending  Fractures. 

A,  Transverse  fracture;   B,  oblique  fracture;   C,  oblique  fracture  with  separa- 
tion of  a  wedge  shaped  fragment. 


widely  dissociated  from  each  other  (fracture  of  coronoid  process  in 
backward  dislocation  of  the  forearm,  etc.),  or  when  ligaments  are 
violently  stretched  and  portions  of  the  bone  to  which  ihey  are  attached 
are  torn  off  (Colics'  fracture).  A  similar  condition  may  be  caused 
by  the  sudden  contraction  of  a  powerful  muscle  (tubercle  of  tibia). 


642     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Torsion  fractures  are  produced  by  forcible  twisting  of  a  long  bone 
when  one  of  its  ends  is  held  still.  A  certain  degree  of  bending  force 
is  probably  also  concerned  in  the  production  of  the  lesion.  The  line 
of  the  fracture  follows  a  spiral  course  in  the  direction  in  which  the 
bone  is  twisted.  As  the  fragments  usually  have  sharp  points,  per- 
foration of  the  soft  parts  (compound  fracture)  is  likely  to  occur.    In 

some  instances  a  wedge  shaped  piece  of 
considerable  size  is  separated  from  the 
shaft  of  the  bone. 

Comminuted  fractures  are  the  result 
of  severe  trauma,  such  as  the  applica- 
tion of  crushing  or  twisting  force  by 
machinery,  and  are  closely  allied  to  the 
class  of  fractures  produced  by  projec- 
tiles. 

The  complications  of  fractures  var}'' 
with  the  force  that  produces  them. 
Fractures  produced  by  direct  violence 
are  complicated  by  contusion  of  the 
skin  and  soft  parts,  and,  for  this  reason, 
are  usually  attended  with  the  forma- 
tion of  hematomata  of  variable  size. 
Fractures  produced  by  indirect  violence 
are  likely  to  be  attended  with  injury  to 
large  hlood  vessels  and  nerves.  This  is 
especially  true  in  cases  of  bending  and 
torsion  fractures  watli  marked  displace- 
ment, in  which  instances  the  soft  parts 
are  often  punctured.  Extensive  injury 
to  the  soft  parts  occurs  in  connection 
with  comminuted  fractures  when  the 
several  fragments  are  driven  into  the 
soft  parts.  Certain  fractures  are  compli- 
cated by  the  involvement  of  special  parts,  such  as  injury  to  the  brain 
in  fracture  of  the  skull,  injury  to  the  spinal  cord  in  fractures  of  the 
vertebrae,  laceration  of  the  urethra  when  the  symphysis  pubis  is 
broken,  and  rupture  of  the  radial  nerve  in  cases  of  fracture  of  the 
middle  third  of  the  humerus. 

A  statistical  study  of  fractures  shows  the  following:  Fractures 
comprise  one  seventh  of  all  injuries  and  occur  ten  times  as  frequently 


Fig.  225. —  Spiral  Fractuke 
OF  Tibia  (Harlem  Hospital 
case). 


INJURIES  TO  THE  OSSEOUS  SYSTEM  643 

as  dislocations.  The  bones  of  the  extremities  are  fractured  more 
frequently  than  those  of  the  head  and  trunk;  those  of  the  arms  more 
often  than  the  legs.  Fractures  of  the  forearm  comprise  eighteen  per 
cent,  followed  closely  by  the  lower  legs,  ribs,  and  clavicles  with  fifteen 
per  cent.  Fractures  of  the  bones  of  the  hand  occur  in  eleven  per 
cent ;  the  upper  arm  seven  per  cent ;  the  femur  six  per  cent ;  the 
bones  of  the  foot  two  and  six  tenths  per  cent ;  the  bones  of  the  face 
two  and  four  tenths  per  cent;  the  cranium  one  and  four  tenths  per 
cent;  the  patella  one  and  three  tenths  per  cent;  the  scapula,  the 
vertebrae,  and  the  pelvis  one  per  cent;  and  the  sternum  one  tenth  of 
one  per  cent  of  the  cases.  Fractures  occur  in  men  four  and  one  half 
times  as  often  as  in  women.  As  to  age :  Most  fractures  occur  in  the 
third  decennium.  The  frequency  of  fractures  gradually  increases 
from  the  tenth  to  the  fortieth  year  and  then  gradually  decreases ; 
still  the  frequency  is  greater  in  the  eighth  and  ninth  decenniums  than 
in  the  first  and  second.  To  this  must  be  added  the  fractures  of  the 
newborn  (birth  fractures). 

Symptoms. —  The  manifestations  of  a  subcutaneous,  closed  or  simple 
fracture  are  subjective  and  objective.  The  subjective  symptoms  are 
jiain  at  the  site  of  fracture  and  lessening  of  function,  which  may  be 
slight  or  complete.  The  latter  symptom  may  be  absent  in  cases  of 
impacted  fracture.  Interference  with  function  ma}'  be  due  to  pain, 
or  may  be  the  result  of  the  loss  of  the  bony  support  of  the  limb.  The 
most  important  objective  symptom  is  deformity  which  includes  all  the 
changes  of  form  and  variations  of  position  of  the  broken  part;  these, 
however,  may  be  masked  by  the  sw^elling  or  may  not  be  manifest  when 
there  is  no  displacement  of  fragments.  The  second  important  sign  of 
a  fracture  is  a  false  point  of  motion  to  which  crepitus  may  be  added. 

The  degree  of  displacement  of  the  fractured  ends  of  a  bone  is 
responsible  for  the  deformity  and  is  dependent  upon  the  provocative 
force,  on  the  weight  of  the  limb  peripheral  to  the  fracture,  on  the 
degree  of  muscular  contraction,  and  on  the  tension  of  the  soft  parts. 

Of  the  various  displacements  four  main  forms  are  generally  recog- 
nized. 

1.  Angular  deviation  at  the  point  of  fracture  occurs  in  bending 
fractures,  and  is  due  to  the  force  which  breaks  the  bone,  but  may  be 
increased  by  the  weight  of  the  displaced  part,  by  the  tension  of  the 
muscles,  b}-  efforts  at  motion  on  part  of  the  injured  person,  or  by 
faulty  manipulations.  In  this  way  angulation  may  occur  in  connec- 
tion M'ith  fractures  that  do  not  at  first  present  this  deformity. 


644     INJURIES  TO  SOFT  PAETS,  BONES  AND  JOINTS 

2.  Lateral  displacement  of  fragments  occurs  in  transverse  frac- 
tures, though  rarely  by  itself,  being  usually  combined  with  other  dis- 
placements. Lateral  displacement  combined  with  angular  deviation 
is  called  '^overriding." 

3.  Displacement  in  the  long  axis  is  associated  with  shortening  or 
lengthening  of  the  bone.  In  the  former,  muscular  contraction  causes 
the  fragments  to  lie  beside  each  other ;  in  the  latter  the  muscles  sep- 
arate the  fragments.  Shortening  is  likely  to  be  marked  in  fractures 
of  diaphyses,  especially  when  the  fragments  present  oblique  surfaces, 
so  that  the  traction  of  the  muscles  causes  them  to  slide  upon  each  other 
and  the  peripheral  portion  of  the  limb  to  be  drawn  toward  the  trunk. 
Lengthening  of  the  bone  occurs  when  the  central  traction  of  muscles 
acts  upon  the  proximal  fragment;  for  instance,  the  action  of  the 
triceps  muscle  upon  a  fractured  olecranon  process. 

Longitudinal  displacement  may  occur  in  impacted  fractures. 

4.  Rotary  displacement  of  one  or  both  fragments  (in  opposite 
directions)  around  the  long  axis  of  the  bone  is  caused  by  the  twist- 
ing action  of  the  productive  force  in  torsion  fractures.  It  also  occurs 
as  the  result  of  the  weight  of  the  peripheral  portion  of  the  injured 
limb  in  fractures  produced  in  other  ways.  This  is  seen  in  fracture  of 
the  lower  leg  in  which  the  weight  of  the  leg  and  foot  causes  the  lower 
fragment  to  rotate  outward. 

5.  Irregular  displacements  occur  in  connection  with  splintered 
fractures,  depressed  and  bursting  fractures  of  the  skull,  etc. 

Diagnosis. —  The  detection  of  a  subcutaneous  fracture  is  made  pos- 
sible by  a  combination  of  factors  which  includes  a  systematic  examina- 
tion in  each  instance. 

A  description  of  the  accident  should  be  obtained  with  a  view  of 
applying  the  knowledge  thus  gained  to  the  general  rules  which  apply 
to  the  production  of  certain  kinds  of  fractures.  Pain  at  the  seat  of 
injury  and  interference  with  function  do  not  indicate  the  presence  of 
a  fracture,  though  they  possess  considerable  diagnostic  value  when 
their  occurrence  is  not  attributable  to  injuries  of  muscles,  tendons, 
ligaments,  etc.  The  exclusion  of  simple  contusion,  sprain,  fissured 
fracture  or  a  dislocation  has  to  be  based  on  a  complete  study  of  the  case. 

Inspection  of  the  injured  area,  comparing  it  with  the  healthy  side, 
often  reveals  the  presence  of  a  typical  fracture  and  does  away  with  the 
more  or  less  painful  palpation. 

Deformity  even  of  moderate  degree  is  of  diagnostic  significance, 
especially  when  it  is  increased  by  efforts  at  voluntary-  motion  on  part 


INJURIES  TO  THE  OSSEOUS  SYSTEM  645 

of  the  patient.  When  the  seat  of  fracture  is  masked  by  the  presence 
of  a  hematoma  or  sivelling  of  the  soft  parts  shortening  may  be  visible, 
though  this  should  be  verified  by  measurements  that  are  compared  to 
the  opposite  uninjured  side  of  the  body.  Rotary  displacement  and 
angular  deviation  are  indicative  of  fracture  and  may  reveal  its 
character  and  location. 

Palpation  indicates  the  changes  in  the  form  of  the  bone,  but  should 
be  addressed  to  both  sides  of  the  body  for  purposes  of  comparison. 
In  this  way  the  sense  of  touch  may  reveal  moderate  displacement  of 
fragments,  a  bend,  a  split,  or  the  presence  of  an  a\Tilsion  fracture. 
Tenderness,  which  is  usually  restricted  to  the  immediate  environment 
of  the  fracture,  is  a  valuable  sign.  When  the  end  of  the  hrohen  hone 
is  dislocated,  its  articular  end  is  palpable  in  a  faulty  position  and  a 
hollow  space  corresponding  to  the  joint  may  be  more  or  less  distinctly 
felt. 

When  the  study  of  an  injury  as  indicated  does  not  justify  the  con- 
clusion that  the  bone  is  fractured,  the  presence  of  a  false  point  of 
motion  may  be  ascertained.  For  the  purpose  the  central  portion  of 
the  bone  or  limb  is  held  immovable  and  the  distal  part  is  moved  in 
various  directions.  The  relationship  of  the  ends  of  the  broken  bone 
to  each  other  may  permit  of  unnatural  mobility  in  only  one  direction. 
In  fractures  located  near  the  trunk  the  hand  may  be  placed  on  the 
articular  end  of  the  bone  and  the  distal  portion  rotated.  AVhen  the 
articular  end  does  not  move  in  accord  with  this  manipulation,  the 
presence  of  a  fracture  may  be  assumed.  In  fractures  of  the  hones  of 
the  trunk  a  false  point  of  motion  may  be  demonstrated  by  pressure 
with  the  fingers  on  either  side  of  the  point  of  separation  of  the 
fragments. 

Ahnormal  motility  is  the  most  positive  sign  of  a  fracture.  Manipu- 
lation of  fragments  of  broken  bone  is  often  attended  with  crepitus; 
however,  this  should  not  be  given  undue  importance  as  a  diagnostic 
sign.  It  is  of  distinct  value  in  connection  with  fractures  in  joints  in 
which  the  other  signs  may  be  indistinct  or  absent.  In  the  shaft  of 
the  bone  it  simply  indicates  that  there  is  no  interposition  of  soft  parts 
between  the  fragments.  Crepitus  elicited  by  simple  pressure  upon  the 
area  of  injury  may  be  due  to  the  presence  of  a  large  coagulum. 

The  Rontgenogram  is  a  most  important  aid  in  the  diagnosis  of  frac- 
tures, as  it  causes  the  shadow  of  the  bone  to  be  recorded  on  a  photo- 
graphic plate.  It  must  be  remembered  that  photographs  of  this  sort 
are  simply  shadows  that  are  likely  to  be  distorted  like  those  thrown  on 


646     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

a  wall  by  a  candlelight,  only  the  distortions  are  of  lesser  degree  (Cod- 
man")  and,  while  the  negative  will  reveal  the  finest  fissures  and  avul- 
sion fractures  and  indicate  the  'position  of  the  fragments,  in  this  con- 
nection an  accurate  interpretation  of  the  conditions  prevailing  in  a 
given  instance  is  only  possible  when  the  mechanics  involved  in  the 
making  of  the  picture  are  taken  into  account,  together  with  a  shadow 
picture  taken  of  the  normal  limb  or  part  under  similar  conditions  for 
the  purpose  of  comparison.  The  ray  is  also  used  in  connection  with 
the  fluoroscope  by  means  of  which  the  reduction  of  fractures  and  their 
proper  immobilization  may  be  facilitated. 

Differentiation  between  a  traumatic  and  a  pathological  fracture 
may  be  difficult,  especially  when  there  has  been  no  evidence  of  dis- 
ease of  the  bone  before  the  lesion  occurs.  When  the  trauma  producing 
a  fracture  is  slight  compared  to  the  extent  of  bone  injur}^,  an  under- 
lying pathological  bone  condition  should  be  suspected.  The  Rontgen- 
ogram  picture  may  be  of  service  in  this  connection.  The  gradual  de- 
velopment of  a  tumor  at  the  site  of  the  fracture  indicates  the  appear- 
ance  of  a,  so-called,  '' callus  tumor"  (usually  sarcoma). 

In  the  clinical  course  of  subcutaneous  fractures  the  soft  parts  con- 
tiguous to  the  bone  lesion  swell  to  a  greater  or  lesser  degree.  This,  as 
is  indicated  by  the  discoloration  of  the  skin,  is  mainly  due  to  the 
collection  and  infiltration  of  blood.  The  swelling  is  greatest  in  cases 
in  which  the  bone  fragments  are  widely  separated  and  cause  injury 
to  the  soft  parts.  Fractures  involving  joints  are  always  attended  with 
the  formation  of  hemarthrosis.  In  many  instances  the  swelling  is 
increased  by  an  edematous  infiltrate  which  has  its  origin  in  a  mild 
form  of  inflammatory  reaction  and  causes  the  skin  to  become  tense 
and,  at  times,  is  attended  with  the  formation  of  serous  or  bloody  blebs. 
This  condition  of  affairs  usually  subsides  in  a  few  days.  During  the 
first  week  following  the  fracture  a  low  grade  of  fever  develops  (so- 
called  aseptic  fever)  which  is  no  doubt  due  to  the  absorption  of  disin- 
tegrated tissues,  and  may  be  attended  with  moderate  transitory 
albuminuria.  The  free  fat  at  times  found  in  the  urine  is  liberated 
from  the  marrow  as  the  result  of  bone  concussion  and  does  not  come 
from  the  site  of  the  fracture  (Ribbert^). 

In  one  or  two  weeks  the  swelling  and  pain  disappear  and  a  distinct 
mass  becomes  palpable  at  the  site  of  the  fracture;  it  is  spindle  shaped 
and  gradually  increases  in  size  for  several  weeks,  slowly  receding 
and  becoming  harder  and  smaller.  This  mass  consists  of  neivly  formed 
bone  tissue  and  is  called  the  callus. 


INJURIES  TO  THE  OSSEOUS  SYSTEM  647 

The  regenerative  tissue  changes  concerned  in  callus  formation  begin 
at  the  end  of  twenty-four  hours  after  the  injury,  and  are  characterized 
by  proliferation  of  osteoblasts  from  the  periosteum  and  hone  marrow. 
Despite  the  fact  that  the  periosteum  is  lacerated  and  may  be  disso- 
ciated from  immediate  contact  with  the  bone,  it  is  concerned  in  the 
formation  of  a  vascular  granulation  tissue  and  at  the  end  of  a  week 
exhibits  numerous  osteoid  and  chondroid  elements,  between  the  layers 
of  which  proliferation  of  marrow  tissue  develops.  This  external,  or 
periosteal,  callus  which  extends  well  beyond  the  area  of  fracture 
** solders"  the  fragments  together,  gradually  becomes  impregnated 
with  lime  salts  and  takes  on  the  characteristics  of  bone,  unless  the 
fragments  are  not  immobilized,  in  which  event  the  newly  formed  tissue 
remains  cartilaginous  in  character.  The  inner,  or  medullary,  callus 
develops  some  time  after  the  outer  and  is  composed  of  osteoblasts 
which  at  first  form  osteoid  tissue  and  later  become  osseous.  The  pro- 
liferation of  new  tissue  temporarily  closes  the  medullary  canal  of  the 
fragments. 

When  the  fragments  of  a  fractured  bone  are  in  normal  appo- 
sition, BY  PROLIFERATION  THE  CELLULAR  ELEMENTS  ORIGINATING  FROM 
THE  PERIOSTEUM  AND   MEDULLARY  CANAL  GRADUALLY  MERGE  INTO  EACH 

OTHER,  forming  a  continuous  bridge  which  ultimately  does  not  differ  in 
any  essential  regard  from  normal  bone.  When  the  fragments  are 
separated  the  space  is  filled  by  a  similar  formation  called  the  inter- 
mediate callus.  Under  the  latter  conditions  complete,  firm,  bony  union 
may  take  place  (Fig.  226) . 

In  some  cases  the  connective  tissue  contiguous  to  a  fracture  takes 
part  in  the  formation  of  new  bone,  especially  when  the  bone  injury 
is  attended  with  contusion  and  laceration  of  the  soft  parts.  Under 
these  conditions  a,  so-called,  periosteal  callus  is  formed  which  is 
attended  with  the  development  of  scaly  projections  that  extend  far 
out  into  the  intermuscular  connective  tissue,  at  times  bridging  neigh- 
boring joints  and  ankylosing  them,  causing  a  condition  of  callus 
luxurians  that  bears  a  resemblance  to  myositis  ossificans.  At  times, 
the  fracture  of  parallel  bones  causes  the  calluses  to  coalesce  so  that  a 
synthesis  is  formed. 

Ordinarily  a  callus  reaches  its  maximum  size  in  about  four  weeks 
and  is  ossified  (consolidated)  at  the  end  of  another  four  weeks.  This 
is  followed  by  the  conversion  of  the  spongy  mass  into  a  smaller,  hard 
compact  one  which  becomes  more  and  more  like  normal  bone.  Gradu- 
ally the  jagged  edges  and  the  more  or  less  separated  splinters  of  hone 


648     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

are  alsorhed.  When  the  fragments  have  been  maintained  in  accurate 
coaptation,  the  medullary  canal  is  reestablished.  In  cases  of  malposi- 
tion it  remains  closed  as  shown  in  Fig-.  226c.  The  spongiosa  is  con- 
verted into  haversian  canals  in  accord  with  the  statistical  law  in  this 
connection  (J.  Wolf,^  Zondek'"'). 

The  amount  of  callus  formation  varies  ividehj.  In  fractures  at- 
tended with  slight  injury  to  the  periosteum,  in  fissured  and  in  green 
stick  fractures  there  is  but  little  callus  formed.     On  the  other  hand, 


?'0 


t^i^V 


m, 
Au 


W 


'H 


A  B  C 

Fig.  226. —  Bony  Union  in  Various  Positions. 
A,   Separation   of  the   fragments;   B,   lateral  displacement  of   the   fragments; 
C,  angulation  of  the  fragments. 

when  the  periosteum  is  extensively  lacerated,  when  the  bone  is  splint- 
ered, or  when  there  is  much  trauma  to  the  soft  parts,  the  inflammatory 
reaction  which  takes  part  in  the  regenerative  process  hecomes  an  asset 
as  regards  ultimate  repair.  As  a  rule,  the  formation  of  callus  is 
greater  in  fractures  of  the  diaphyses  than  in  the  epiphyses,  although 
repair  of  the  latter  is  at  times  attended  with  the  formation  of  a  callus 
luxurians,  especially  when  comminution  occurs.  In  the  short  and  flat 
bones  the  callus  is  furnished  by  the  medullar}^  substance  and  is  usu- 


INJURIES  TO  THE  OSSEOUS  SYSTEM  64$ 

ally  small  in  amount.  Extensive  periosteal  callus  development  is  at 
times  attended  with  the  formation  of  hone  cysts  (Frangenheim*^). 
Excessive  proliferation  of  periosteal  callus  {traumatic  osteoma)  fol- 
lowing- injur}'  to  the  bone  (other  than  fracture)  is  reported  by  Fritz 
KoenigJ 

The  repair  of  cartilage  takes  place  by  proliferation  from  the  peri- 
chondrium, which  at  first  possesses  the  characteristics  of  connective 
tissue  and  later  those  of  the  spongiosa.  Articular  cartilage  heals  by 
connective  tissue  cicatrization. 

The  time  required  for  the  healing  of  a  simple  fracture  averages 
about  sixty  days,  though  it  varies  considerably  in  different  bones. 
Observations  in  this  connection  show  that  the  phalanges  heal  in  two 
weeks;  the  metacarpal  and  metatarsal  bones  and  the  ribs  in  three; 
the  clavicle  in  four ;  the  bones  of  the  forearm  in  five ;  the  humerus 
and  fibula  in  six ;  the  neck  of  the  humerus  and  the  tibia  in  seven ;  both 
bones  of  the  leg  in  eight ;  the  femur  in  ten  and  the  neck  of  the  femur 
in  twelve  weeks.  In  children  all  fractures  unite  early;  most  of  them 
in  from  two  to  three  weeks. 

The  causes  which  interfere  with  the  union  of  fractures  are  consti- 
tutional and  local.  When  the  general  condition  of  the  patient  is 
faulty  as  the  result  of  a  general  infectious  disease,  the  presence  of  a 
malignant  growth  (cachexia),  or,  in  cases  of  senile  marasmus,  atrophy 
of  the  bone  due  to  diseases  of  the  central  nervous  system,  and  in 
cases  of  rachitis  or  osteomalacia,  the  formation  of  callus  is  tardy  or 
may  be  absent.  The  local  causes  are  wide  separation  or  overriding  of 
the  fragments,  the  interposition  of  soft  parts  (muscles,  tendons,  por- 
tions of  a  joint  capsule,  etc.),  large  hematomata  between  the  frag- 
ments, extensive  destruction  of  the  periosteum  and  medullary  suh- 
stance  in  connection  with  comminution,  lack  of  nourishment  of  one  of 
the  fragments  (in  fractures  involving  joints  or  epiphyses),  incom- 
plete immobilization  of  the  fracture,  and  pyogenic  ostitis  or  necrosis 
the  result  of  hematogenous  or  lymphogenous  infection. 

Under  these  circumstances  the  formation  of  callus  may  be  delayed 
or  absent.  In  the  former  instance  the  callus  develops  very  slowly  but 
firm  union  is  ultimately  achieved,  a  fact  worthy  of  note,  since  prema- 
ture use  of  the  limb  may  result  in  refracture.  In  a  certain  number  of 
cases  the  irritation  consequent  to  refracture  is  followed  by  acceleration 
of  the  process  of  repair.  "When  there  is  no  evidence  of  callus  forma- 
tion at  the  end  of  a  reasonable  period  of  time  a  false  point  of  motion 
is  persistently  maintained.     The  condition  is  designated  as  a  pseud- 


650     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

arthrosis.  A  pseudarthrosis  of  this  sort  indicates  that  the  fragments 
are  separated  by  the  interposition  of  soft  parts,  or  that  these  are 
simply  connected  by  the  formation  of  a  connective  tissue  iridge  which 
does  not  take  on  the  character  of  bone.  In  rare  instances  a  genuine 
nearthrosis  is  formed  at  the  seat  of  a  fracture  in  which  the  ends  of 
the  fragments  are  rounded  off,  become  covered  with  a  layer  of  carti- 
lage and  are  embedded  in  a  connective  tissue  capsule,  thus  presenting 
a  condition,  of  affairs  closely  resembling  a  joint.  The  degree  of  inter- 
ference with  function  caused  by  false  joints  of  this  sort  depends  upon 
their  location ;  for  instance,  in  a  rib  no  disturbance  would  arise,  but 
when  located  in  a  long  bone,  such  as  the  femur,  locomotion  is  seriously 
impaired. 

The  pernicious  sequelae  of  simple  fractures  are  caused  by  the  coin- 
cident injury  of  the  soft  parts,  by  faulty  reduction,  and  by  prolonged 
immohilization  of  the  injured  part. 

Concussion  of  hone  marrow  is  more  or  less  inevitable  in  connection 
with  all  fractures.  As  a  rule,  the  fat  thus  liberated  is  not  of  clinical 
importance;  however,  in  a  certain  number  of  instances,  fat  emholism 
occurs  (p.  949).  Injuries  to  arteries,  veins,  nerves,  tendons,  a7id 
muscles  may  be  due  directly  to  the  force  which  produced  the  fracture 
or  may  be  caused  by  the  ends  of  the  fragments,  either  at  the  time  of 
the  injury  or  during  transportation  of  the  patient  when  the  part  is  not 
immobilized.  Extensive  extravasation  of  Mood,  pulsating  hematomata, 
traumatic  aneurism,  thromhosis,  necrosis  of  the  injured  liml),  paraly- 
sis from  nerve  injury  or  from  pressure  by  callus  formation  and  conse- 
quent muscular  contracture  are  not  uncommon  complications  of  frac- 
tures. Fractures  extending  into  joints  are  likely  to  limit  motion  and 
cause  the  separation  of  portions  of  articular  cartilage  which  later  be- 
come free  bodies  and  provoke  the  clinical  picture  of  a  joint  mouse. 
In  some  cases  the  hemarthrosis  attendant  upon  a  fracture  which  en- 
croaches upon  a  joint  is  followed  by  stretching  of  the  capsule  and  con- 
sequent joint  disturbances. 

The  location  of  a  fracture  and  the  anatomical  structures  contiguous 
to  it  must  be  taken  into  account  with  the  view  of  recognizing  the 
effect  of  pressure  of  the  fragments  upon  nerves  and  Mood  vessels.. 
This  is  illustrated  in  a  fracture  of  the  humerus  in  which  the  radial 
nerve  may  be  injured  by  a  fragment  or  paralyzed  by  becoming  em- 
bedded in  the  callus.  In  simple  fractures,  necrosis  of  a  fragment  is 
rare. 

Prolonged  disuse  and  protracted  immohilization  are  followed  by 


INJURIES  TO  THE  OSSEOUS  SYSTEM  651 

trophic  disturbances  which  are  evinced  by  rapid  shrinkage  of  the  soft 
parts.  The  skin  becomes  soft,  thin,  and  glistening ;  the  muscles  shrivel, 
partly  from  disuse  and  partly  because  of  reflex  influences  originating 
in  the  trophic  centers  of  the  cord,  the  result  of  prolonged  peripheral 
irritation.  Rontgcnographic  studies  show  that  in  from  six  to  eight 
weeks  the  structure  of  the  bone  undergoes  distinct  sj^mmetrical 
atrophy.  The  muscles  and  fascia  atrophy;  the  tendons  do  not  glide 
readily  in  their  sheaths — especially  when  there  has  been  much  effusion 
of  blood;  the  joints  (even  though  not  involved)  lose  range  of  motion, 
particularly  in  elderly  persons  in  whom  shrinkage  of  the  capsule, 
coadhesion  of  the  synovia,  and  degeneration  of  articular  cartilages 
not  infrequently  occur.  When  joints  of  this  sort  are  forcibly  moved 
after  the  fracture  is  healed,  the  shrunken  capsule  is  likely  to  tear 
and  cause  hemarthrosis  and  permanent  impairment  of  function.  In 
children,  excessively  prolonged  immobilization  may  result  in  retarded 
development  of  the  entire  limb,  which  in  some  instances  is  followed  by 
permanent  asymmetry. 

Circulatory  disturbances  are  especially  manifest  in  the  lower  ex- 
tremities and  are  expressed  by  stasis  and  edema,  the  result  of  the 
absence  of  muscular  contractions  over  a  long  period  of  time. 

In  old  persons  the  prolonged  maintenance  of  the  supine  position 
predisposes  to  the  formation  of  bed  sores  and  the  development  of 
hypostatic  pneumonitis. 

Serious  complications  follow  the  occurrence  of  venous  thromhosh 
which  is  followed  by  prolonged  edema  of  the  part,  and  may  cause 
pulmonary  and  cardiac  embolism  with  a  fatal  outcome.  These  are 
due  to  a  combination  of  causes,  i.  e.,  injury  of  the  smaller  veins  at  the 
seat  of  the  fracture,  pressure  upon  veins  from  the  callus,  and  enfeebled 
cardiac  action  and  consequent  slowing  of  the  circulation.  Conditions 
of  this  sort  are  comparatively  rare  and  occur  in  elderly  persons  about 
the  second  or  third  week  after  the  injury. 

In  old  people,  the  persistence  of  pain  at  the  site  of  the  fracture 
is  likely  to  be  an  important  factor.  It  is  usually  exacerbated  by 
changes  of  weather  and  interferes  with  return  of  function. 

The  end  results  in  cases  of  simple  fracture  vary  with  the  form  of 
fracture  and  the  particular  bone  involved.  In  a  general  way  it  may 
be  said  that,  in  fissures,  infractions,  and  fractures  with  moderate 
displacement,  the  outlook  is  favorable.  On  the  other  hand,  in  cases 
of  comminution,  in  marked  displacement  of  fragments  wnth  much 
trauma  to  the  soft  parts,  and  in  fractures  extending  into  joints, 
shortening,   pseudarthrosis,   and   impairment   of   joint  function   are 


652     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

likel}^  to  occur.  Of  course  the  general  condition  of  the  patient  has  a 
determining  influence  upon  the  outcome. 

Treatment. —  The  treatment  of  simple  fractures  relates  primarily 
to  first  aid  measures.  In  all  cases  of  fractures  that  do  not  occur 
in  the  home  of  the  patient,  provision  should  be  made  for  transporta- 
tion under  conditions  that  obviate  damage  to  the  soft  parts  by  the 
fragments  which,  above  all  else,  should  be  prevented  from  penetrat- 
ing the  skin  (compound  fracture).  For  the  purpose  the  arm  maj'  be 
fastened  to  the  body  by  means  of  articles  of  clothing,  towels,  etc. 
Fractures  of  the  legs  present  a  more  difficult  problem  in  this  con- 
nection. In  this  situation,  fractures  may  be  temporarily  immobi- 
lized by  fastening  the  injured  part  to  a  walking  stick,  a  bed  slat,  an 
umbrella,  a  broomstick,  a  board,  or  a  similar  object  which  should  be 
so  adjusted  as  to  hold  quiescent  the  joints  at  either  side  of  the  fracture. 
Soldiers  should  be  trained  to  use  sabers,  rifles,  bayonets,  etc.,  for  the 
purpose.  The  injured  limb  should  be  fastened  to  the  improvised 
splint  by  means  of  handkerchiefs,  straps,  rope,  suspenders,  or  portions 
of  attire  such  as  a  muffler,  etc. 

When  it  is  not  necessary  to  transport  the  patient,  the  fracture  may 
be  held  still  by  embedding  the  injured  part  in  pillows,  which  may  be 
kept  in  place  by  towels,  etc.,  or  the  limb  may  be  held  quiescent  by 
means  of  stockings  filled  wnth  sand. 

The  treatment  of  every  fracture  is  aimed  at  obtaining  firm  bony  union  with 
the  fragments  in  normal  apposition  and  complete  resumption  of  function. 

The  general  principles  involved  in  the  problem  relate  primaril}^  to 
reduction  of  the  deformity,  i,  e.,  placing  the  fragments  in  normal  rela- 
tionship to  one  another. 

The  reduction  of  a  fracture  should  be  accomplished  under  narcosis 
whenever  possible.  This  is  followed  by  thorough  cleansing  of  the  skin 
with  the  view  of  obviating  infection  of  superficial  abrasions,  blebs  or 
hematomata. 

While  most  fractures  of  the  trimh  and  face  are  easily  reduced  by 
simple  pressure,  and  many  of  those  involving  joints  are  placed  in  ap- 
position by  appropriate  posture  of  the  limb,  the  reduction  of  fractures 
of  the  bones  of  the  extremities  is  accomplished  only  by  carefully  exe- 
cuted manipulation.  For  the  purpose,  the  limh  central  to  the  site  of 
fracture  is  firmly  fixed  by  an  assistant  or  by  the  use  of  especially 
devised  apparatus  (such  as  the  Hawley  table)  while  the  surgeon 
grasps  the  peripheral  portion  and,  by  traction,  tivisting,  bending,  or 


INJURIES  TO  THE  OSSEOUS  SYSTEM 


653 


lateral  motion,  manipulates  the  distal  fragment  into  proper  relation- 
ship with  the  central  one.  When  the  central  fragment  is  displaced  by 
muscular  contraction  the  distal  portion  of  the  limb  must  be  aligned 
with  the  former.  For  instance,  the  foreann  is  placed  in  full  exten- 
sion in  cases  of  fracture  of  the  olecranon,  and  the  knee  is  flexed 
(double  inclined  plane)  in  fractures  of  the  middle  and  upper  thirds  of 
the  shaft  of  the  femur.  In  fractures  in  the  region  of  joints,  the  dis- 
placement must  be  corrected  by  over  extension  or  flexion  of  the  joint, 
i.  e.,  in  typical  fractures  of  the  radius  (Colics'  fracture)  the  hand 
should  be  flexed,  abducted  or  pronated. 

After  the  fracture  has  been  reduced  the  part  should  be  immobilized 
in  the  corrected  position. 


Fig.  227. —  Molded  Gypsum  Dressing  Being  ' '  Fitted  ' '  to  the  Leg. 


In  many  instances  (though  by  no  means  in  all  cases)  immobilization 
of  a  fracture  may  be  accomplished  by  an  appropriate  retention  dress- 
ing. In  fresh  cases,  when  there  is  not  much  swelling  of  the  soft  parts, 
there  is  nothing  that  will  take  the  place  of  the  gypsum  handage.  In 
cases  attended  with  extensive  effusion  of  hlood  (which  usually  increases 
as  the  result  of  motility  of  the  fragments,  during  the  preliminary 
treatment  with  icebags,  lotions,  etc.),  the  part  may  be  held  quiescent 
in  well  padded  splints  made  of  wood,  tin,  wire,  cardboard,  etc.,  held  in 
place  with  starch  bandages.  During  this  time  the  injured  limb  should 
be  kept  in  an  elevated  position. 

The  gypsum  dressing  is  used  in  two  ways :  As  a  circular  dressing, 
encasing  the  part ;  or  as  a  molded  splint.  In  the  circular  method  the 
bandage  consists  of  crinoline  or  a  wide  meshed  cheesecloth  (the  former 


654    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

is  preferable),  into  which  dry  gypsum  has  been  incorporated.  The 
limb  is  enveloped  in  tubular  tricot  fabric,  or  better,  in  a  layer  of  cot- 
ton sheeting  covered  with  a  lint  roller  bandage.  Bony  prominences 
and  prominent  tendons  should  he  protected  hy  pads  of  cotton.  The 
web  gypsum  bandage  is  then  applied  and  may  be  reinforced  by  the 
interposition  of  wooden  splints  or  strips  of  metal  between  its  layers. 
This  is  especially  advisable  in  connection  with  the  immobilization  of 
the  femur  and  humerus. 

The  molded  gypsum  dressing  (Beely,®  1878)  possesses  (in  some 
cases)  certain  advantages  over  the  circular.  In  consists  of  practically 
the  same  material  as  is  used  for  the  circular  method,  but  the  wet 
gypsum  bandage  is  arranged  in  a  manner  conforming  to  the  general 
outline  of  the  limb  and  is  then  applied  to  the  injured  part  and  made 


Fig.  228. —  Gypsum  Splints  Removed,  Showing  How  They  Con- 
form TO  THE  Contour  of  the  Limb. 

finally  to  conform  to  it  hy  means  of  an  ordinarj^  roller  bandage  (Figs. 
227  and  228).  At  the  end  of  twenty-four  hours  the  roller  bandage  is 
removed  and  the  splints  held  in  place  by  strips  of  adhesive  plaster 
or  similar  device.  The  great  advantage  of  the  method  lies  in  the 
ease  with  which  it  may  be  removed  and  reapplied.  However,  the 
circular  dressing  may  be  cut  down  also,  a  small  sector  removed  and 
the  remaining  portion  finished  by  binding  the  edges  and  punching 
eyelets  in  it  to  permit  of  lacing.  In  this  way  the  injured  part  becomes 
readily  accessible  for  the  purpose  of  treatment  as  stated  (Fig.  229). 

The  USE  OF  EVERY  IMMOBILIZATION  APPARATUS  IS  FOLLOWED  BY  SERIOUS 
DISTURBANCES,  WHEN   IT   IS   TOO   TIGHTLY  APPLIED,   OR   WHEN   IT   MAKES 

UNDUE  PRESSURE  UPON  THE  SOFT  PARTS.  The  dressing  should  be  so  ar- 
ranged that  the  fingers  or  toes  are  exposed  and  the  condition  of  the 
circulation  may  be  noted.     Omission  of  these  precautions  may  result 


INJUKIES  TO  THE  OSSEOUS  SYSTEM 


655 


in  stasis,  ischemia  or  paralijsis,  and  in  some  cases  in  thrombosis  of  the 
vessels  and  gangrene  of  an  entire  limb.  Smaller  areas  of  pressure 
necrosis  present  favorable  ports  of  entrance  for  infection. 

The  first  dressing  should  he  changed  at  the  end  of  a  week,  nevei* 
later  than  the  end  of  the  second  iveek,  when  the  swelling  will  have  dis- 
appeared and  the  dressing  will  require  readjustment.  In  many  in- 
stances, improvement  in  the  alignment  of  the  fragments  may  be  ob- 
tained at  this  time.     The  skin  is  again  cleansed,  ^abrasions  or  areas 

of  irritation  covered  with  sterile  ointment  and 
mild  massage  and  passive  motion  of  joints 
indulged  in. 

At  the  second  dressing  the  padding  may  be 
lessened  or  entirely  disi^ensed  with  and  the 
gypsum  apparatus  applied  over  a  simple 
tricot  fabric  or  directly  to  the  skin.  In  this 
way  the  immobilizing  apparatus  is  brought  in 
more  intimate  contact  with  the  part  and  more 
definite  correction  of  the  deformity  is  attained. 
As  it  is  essential  that  the  disadvantages  of 
prolonged  immobilization  be — as  far  as  pos- 
sible— obviated  by  frequent  massage  and  pas- 
sive motion  of  the  joints,  the  second  dressing 
should  be  arranged  in  a  manner  permitting  of 
its  frequent  removal  and  reapplication  (see 
above). 

The  anihulatory  treatment  of  cases  of  frac- 
ture involving  the  lower  extremities  is  of  value 
in  elderly  persons.  The  application  of  appar- 
atus of  this  sort  is  a  complicated  process. 
Scudder®  says  "The  method  requires  a  cer- 

AND      Puncturing      of  tain  skill  in  adjustment  and  necessitates  the 
Eyelets   for  Lacing.  .  j^     c    i  n    -^  a.     •  ^         ^     ^ 

emploATnent  of  deiinite  materials  not  always 

easily  obtainable.  It  is,  therefore,  not  a  method  of  universal  appli- 
cation." Very  useful  splints  may  be  fashioned  after  the  method  of 
Thomas^"  and  v.  Bruns.^^  Heavy  circular  g;\'psum  dressings  in  which 
steel  walking  stirrups  are  embedded  may  be  used  to  advantage  ( Albers, 
V.  Bardeleben  aiid  KorscV-),  though  their  application  calls  for  the 
exercise  of  considerable  ingenuity  on  part  of  the  surgeon  to  meet  the 
demands  of  a  given  case.  Kemovable  molded  splints  with  steel  lock 
joints  have  been  devised  by  v.  Eiselsberg^^  and  Lexer,^*  which  are 


Fig.  229. —  Circular  Gyp- 
sum   Dressing    Ee- 

MO\'ED     FROM     LiMB     AND 

Finished     by     Binding 


656     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

most  ingenious  and  fill  the  purpose,  but  their  application  requires  the 
cooperation  of  the  mechanic,  a  condition  of  affairs  not  readily 
obtainable. 

Extension  apparatus  (Buck,  1867,  v.  Volkmann,^^  Bardenheuer^") 
is  used  when  manipulations  do  not  succeed  in  accomplishiug  reduction 
of  the  fracture,  and  when  muscular  contraction  causes  recurrence  of 
the  deformity  so  that  immobilization  in  the  corrected  position  is  im- 
possible. The  method  is  a  useful  one  and  often  accomplishes  the 
desired  end;  however,  the  general  rule  may  be  here  laid  down  that, 
if  reduction  of  deformity  and  immobilization  of  a  fracture  is  possible, 
so  that  the  apparatus  used  becomes  a  part  of  every  movement  of  the 
patient,  it  is  a  far  more  desirable  method  of  treatment  than  fastening 
the  apparatus  to  the  bed  and  making  the  patient's  position  conform 
to  it.  In  practice  the  truth  of  this  is  apparent,  as  changes  of  posture 
on  the  part  of  the  patient,  prejudicial  to  the  desired  end,  are  certain 
to  occur  despite  the  greatest  vigilance  on  the  part  of  the  attendants. 
In  a  general  way  it  is  proper  to  say  that  extension  and  counterexten- 
sion  have  a  distinct  place  in  the  treatment  of  certain  fractures,  but 
that  they  are  not  as.  certain  in  regard  to  favorable  outcome  as  obtains 
in  reduction  of  deformity  by  manipulations,  posture,  and  immobiliza- 
tion, as  described  in  connection  with  the  gypsum  dressing.  The 
method  of  applying  the  extension  dressing  is  described  in  connection 
with  its  application  in  a  case  of  fracture  of  the  neck  of  the  femur 
(p. 739). 

The  advantages  claimed  for  the  extension  dressing  are  that  it  over- 
comes overriding  and  rotary  displacement  of  the  fragments,  that  it 
permits  of  frequent  investigation  of  the  position  of  the  fracture,  and 
that  the  joints  may  be  moved  as  desired  with  the  view  of  obviating 
lessening  of  function  (Bardenheuer^'^).  It  is  also  claimed  that  the 
slight  motility  of  the  fragments  coincident  to  this  form  of  apparatus 
does  not  interfere  with  prompt  and  firm  bony  union.  The  method 
is  employed  largely  in  the  treatment  of  fractures  of  the  femur,  though 
it  is  used  also  in  cases  of  fracture  of  the  upper  extremity  involving 
the  elbow  and  shoulder  joints  (Bardenheuer^^) .  Whenever  the  method 
is  used,  joint  function  returns  very  early  and  is  likely  to  be  complete, 
but  its  employment  does  not  by  any  means  exclude  the  possibility  of 
union  in  a  faulty  position. 

In  this  connection  Blake,^'^  basing  his  conclusions  upon  his  obser- 
vations of  the  treatment  of  gunshot  fractures,  has  described  a  method 
of  treatment  substantially  as  given  below, 


INJURIES  TO  THE  OSSEOUS  SYSTEM  657 

The  treatment  which  is  finding  greatest  favor  and  gradually  becom- 
ing generalized  is  suspension  of  the  member  combined  with  traction. 
A  simple  form  of  splint  acting  as  a  cradle  is  used  or  no  splint  at  all, 
and  the  limb  is  suspended  to  an  overhead  frame  with  or  without  a 
trolley  attachment.  Traction  is  applied  b}-  a  weight  attached  to  a  cord 
running  over  a  pulley,  or  simply  by  utilizing  the  weight  of  the  patient. 
The  limb  is  suspended  in  a  position  of  flexion,  rotation  or  abduction 
which  as  nearly  as  possible  coincides  with  that  of  physiological  rest 
for  the  opposing  muscle,  i.  e.,  those  tending  to  cause  deformity.  This 
position  of  physiological  rest  is  a  most  important  object  to  attain,  for 
with  it  little  force  is  necessary  to  keep  the  fragments  in  place.  Unfor- 
tunately, on  account  of  wounds,  infection  and  other  complications,  it 
is  often  impossible  to  accomplish  it,  but  it  should  alwa3's  be  the  goal 
aimed  at. 

The  great  advantages  of  this  system  become  at  once  apparent  to  one 
who  has  struggled  with  other  methods — the  circulation  is  better,  the 
wounds  are  accessible,  union  is  if  anything  more  rapid,  and,  greatest 
boon  of  all,  the  patient  has  no  pain.  Furthermore,  the  articulations 
are  seldom  fixed  and  the  muscles  are  always  accessible  for  massage. 

In  order  to  suspend  fractured  limbs  some  sort  of  overhead  frame 
or  apparatus  is  necessary.  The  original  Balkbn  frame  consists  of  a 
single  horizontal  bar,  longer  than  the  bed,  supported  by  two  posts 
set  on  the  foot  pieces  in  order  to  make  the  apparatus  stable  and  allow 
it  at  the  same  time  to  be  moved  from  one  bed  to  another.  This  frame 
has  the  disadvantage  of  having  only  one  bar,  of  being  too  low,  of 
being  heavy  and  clumsy  and  only  suitable  for  the  lower  extremity. 

The  frame  shown  in  Fig.  2-30  by  itself,  and  in  use  in  the  figures 
illustrating  the  method  of  suspending  several  special  fractures,  is 
free  from  most  of  the  above  defects  and  has  proved  its  practicability. 
It  has  the  disadvantage  of  being  difficult  to  attach  to  beds  that  are 
not  supported  on  legs  at  the  corners ;  but  this  can  be  overcome  by  nail- 
ing longitudinal  bars  of  the  length  of  the  bed  to  the  feet  of  each  pair 
of  frames,  and  thus  fastening  them  together  under  the  bed,  or  by 
simply  nailing  the  feet  to  the  floor. 

The  apparatus  consists  of  two  similar  frames,  one  of  which  is  tied 
to  the  foot  and  the  other  to  the  head  of  the  bed.  Each  frame  is  com- 
posed of  two  uprights  united  by  two  cross  members;  the  lower  one  a  I; 
the  level  of  the  top  of  the  mattress,  the  upper  one  far  enough  below 
the  upper  ends  of  the  uprights  to  avoid  splitting  the  ends  of  the  latter 
by  the  screws  or  bolts  which  are  used  to  fasten  them  together.     The 


658     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

upper  cross  member  is  notched,  as  shown  in  the  diagrams,  to  receive 
the  longitudinal  bars,  which  are  also  notched.  Several  extra  notches, 
two  outside  and  two  inside  of  each  upright,  are  made  in  the  cross 
member  to  receive  the  longitudinal  bars  in  the  proper  position  over 
the  limb  to  be  suspended.  Only  two  notches  are  made  in  the  longitudi- 
nal bars,  the  distance  between  them  being  the  exact  length  of  the  bed. 
The  interlocking  of  the  notches  prevents  the  longitudinal  bars  from 
slipping  and  makes  the  entire  frame  rigid. 


Fig.  230. —  Suspension  Frame  tor  Fractures;   Modified  Balkan  Frame 

(Blake). 


The  end  frames,  as  will  be  seen  by  the  diagrams,  are  made  in  the 
shape  of  a  truncated  ''A,"  the  uprights  below  being  separated  slightly 
more  than  the  feet  of  the  bed,  while  the  upper  ends  are  closer  together. 
Each  upright,  E-F  Fig.  230,  is  2  meters  (80  in.)  long.  The  upper 
cross  piece,  A-B,  is  1  meter  (40  in.)  long.  The  lower  cross  piece,  C-D, 
is  as  long  as  the  bed  is  wide,  so  that  at  the  level  of  the  top  of  the  mat- 


INJURIES  TO  THE  OSSEOUS  SYSTEM 


659 


tress  the  separation  of  the  uprights  is  exactly  the  width  of  the  bed.  The 
lower  ends  of  the  uprights  are  separated  about  0.20  meter  (8  in.) 
nearer  together.  The  pieces  of  the  end  frames  are  fastened  together 
with  two  screws  or  carriage  bolts  at  each  point.  Bolts  are  better  for 
frames  to  be  knocked  down  for  transportation. 

The  best  material  for  the  purpose  is  soft  white  pine  free  from 
knots;  this  does  not  split  and  the  eyes  or  screws  of  the  pulleys  are 
easily  inserted  in  it.  Any  wood  may  be  used,  however.  Using  soft 
pine,  Blake  has  found  material  0.021  meter  (7/8  in.)  thick  and 
0.05  meter  (2  in.)  wide  for  the  uprights  and  lower  cross  piece  suffi- 
cient, while  for  the  upper  cross  piece  and  the  longitudinal  bars  slightly 
wider  material,  0.06  meter  (2i/^  in.),  should  be  used.    The  longitudinal 


Fig.  231. 


■  Detail  of  Trolley  Bar  for  Suspending  the  Lower 
Limb   (Blake). 


bars  are  2.65  meters  (10  ft.  4  in.)  long  and  project  over  the  ends  of 
the  frames  so  as  to  allow  the  weights  to  hang  bej'ond  the  head  and  foot 
of  the  bed. 

Suspension  is  effected  by  strong  cord  passing  through  pullej^s.  The 
pulleys  used  are  the  ordinary  iron  ones  found  in  any  hardware  shop, 
furnished  with  a  screw  to  fasten  in  the  wood  or  with  a  hook  which  is 
fastened  into  a  screw  eye. 

To  permit  the  patient  to  move  longitudinally  in  the  bed,  as  in  the 
change  of  posture  from  lying  down  to  sitting,  it  is  advisable  to  have 
a  short  bar  to  which  the  limb  and  weights  are  hung,  and  which  moves 
on  a  trolley  attached  to  the  longitudinal  bar  attached  to  the  main 
frame.  This  bar  is  made  of  a  piece  of  wood  0.30  meter  to  0.45  meter 
(12  in.  to  17  in.)  long  (Fig.  231),  in  the  bottom  of  which  are  screwed 


660     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

the  pulleys  through  which  the  cords  for  the  suspension  pass.  Two 
puller's  are  screwed  into  its  upper  side  aud  run  on  an  iron  rod  10  milli- 
meters (3/8  in.)  thick.  One  end  of  this  rod  is  bent  and  tied  to  the 
main  longitudinal  bar,  while  the  other  is  straight  in  order  to  allow  it 
to  engage  the  pulleys;  it  is  passed  through  a  hole  in  a  piece  of  strap 
iron  bent  at  right  angles,  which  is  in  turn  fastened  to  the  longitudinal 
bar  by  two  screws. 

In  practice  it  has  been  found  that  the  trolley  attachment  is  very 
important  for  suspending  the  lower,  but  is  superfluous  for  the  upper 
extremity. 

The  best  weights  are  cast  from  lead,  weigh  500  grams  each,  and 
are  strung  on  an  iron  rod,  but  when  they  hang  over  the  patient  in  such 
a  position  that  he  or  the  attendants  may  strike  against  them  it  is 
better  to  use  small  bags  of  shot,  each  holding  250  grams,  placed  in  a 
larger  bag  of  strong  muslin.  These  smaller  weights  permit  a  more 
delicate  adjusiment  for  the  arm  and  forearm.  Failing  shot  or  lead, 
sand  or  stones  may  be  used. 

For  suspension  of  the  arm  a  simple  post  with  a  horizontal  arm 
may  be  used,  but  the  frames  just  described  are  adapted  for  the 
treatment  of  all  fractures. 

The  several  methods  of  suspension  and  traction  are  discussed  under 
the  headings  of  the  different  fractures. 

For  direct  attachment  of  the  apparatus,  Blake  used  Sinclair's  glue 
(glue  50  parts,  water  50  parts,  glycerin  2  parts,  calcium  chlorid  1 
part,  thymol  1  part)  which,  being  an  aqueous  preparation,  is  well 
borne  by  the  skin. 

In  order  to  avoid  the  objectionable  effects  of  prolonged  extension 
with  weights  (stretching  of  joint  capsules,  tendons,  and  other  soft 
parts)  reduction  of  the  deformity  and  immobilization  of  the  limb  by 
relaxation  posture  may  be  resorted  to.  The  method  has  proved  effec- 
tual in  cases  of  fracture  of  the  lower  end  of  the  femur,  in  which  the 
employment  of  the  double  inclined  plane  extends  the  hip  and  flexes 
the  knee  (Bardenheuer  and  Grasner,^**  Zuppinger  and  Christen"). 

In  most  methods  of  extension,  traction  is  made  on  the  soft  parts, 
which,  as  already  stated,  are  more  or  less  iinfavorably  influenced 
thereby.  With  the  view  of  making  direct  traction  the  employment  of 
nails  driven  into  the  hone,  devised  by  Codevilla-°  (1903)  and  perfected 
by  Steinmann-^  (1907),  to  which  extension  apparatus  may  be  attached, 
serves  a  useful  purpose  in  a  certain  restricted  class  of  cases  (p.  796). 
The  bones  adapted  for  the  procedure  are  the  os  calcis,  the  tuberosity 


INJURIES  TO  THE  OSSEOUS  SYSTEM  661 

of  the  tibia,  and  the  condyles  of  the  femur.  The  advantages  claimed 
for  the  method  are :  That  traction  may  be  made  in  any  desired  direc- 
tion ;  that  the  seat  of  fracture  does  not  need  to  be  encumbered  with 
heavy  immobilizing  dressings;  and  that  the  limb  is  constantly  avail- 
able for  purposes  of  massage  and  passive  motion.  In  cases  of  marked 
overriding,  which  have  not  been  found  reducible  by  other  means,  the 
use  of  the  method  would  seem  to  be  justified. 

The  importance  of  achieving  restoration  of  function  in  cases  of 
fracture  must  not  be  lost  sight  of.  In  a  general  way,  permanent  loss 
of  function  is  attributable  to  ankylosis  of  joints,  to  the  adherence  of 
tendons,  and  to  malposition  of  the  fragments. 

The  first  cause  (ankylosis)  is  directly  traceable  to  prolonged  immo- 
bilization of  the  fracture. 

The  pioneer  opponent  of  prolonged  immobilization  in  cases  of  frac- 
ture, Lucas  Championniere,'-  showed  that  a  certain  number  of  frac- 
tures not  attended  with  much  deformity  could  be  successfully  treated 
by  means  of  massage  and  passive  motion  alone,  and  also  maintained 
that  the  use  of  immohiUzing  apparatus  was  only  necessary  in  cases 
of  marked  displacement  of  the  fragments,  and  then  only  for  a  period 
of  not  more  than  two  weeks.  Championniere  established  a  valuable 
principle  in  the  treatment  of  fractures,  but  there  is  no  doubt  that  his 
views  were  too  radical. 

The  value  of  earlg  passive  motion  and  massage  is  indisputable.  It 
is  also  true  that  union  of  a  fracture  with  moderate  displacement  of 
the  fragments  and  complete  restoration  of  function  is  more  desirable 
than  is  union  in  accurate  alignment  with  an  ankylosed  joint  and 
atrophied  muscles;  however,  that  is  no  reason  why  efforts  at  union  in 
good  position  should  be  neglected,  especially  when  the  principle  of 
Championniere  and  the  emplojnnent  of  immobilizing  apparatus  can  be 
so  readily  combined  (Blake,^^  Jordan^^). 

The  PROPER  ALIGNMENT  OF  THE  FRAGMENTS  MUST  BE  MAINTAINED  BY 
THE  USE  OF  IMMOBILIZING  OR  EXTENSION  APPARATUS  IN  EVERY  FRAC- 
TURE. However,  this  need  not  be  prolonged  until  firm  bony  union  is 
established,  hut  only  until  the  process  of  repair  is  sufficiently  advanced 
to  hold  the  fragments  in  position,  which  in  most  instances  does  not  ex- 
ceed two  or  three  weeks.  Even  during  the  period  of  iinmobilization 
the  apparatus  should,  when  possible,  be  arranged  so  as  to  permit  of 
passive  motion  and  massage,  especially  when  the  fracture  extends 
into  a  joint. 


662     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

In  children,  early  massage  leads  to  excessive  formation  of  callus,  and 
prolonged  immohilization  of  joints  does  no  harm. 

In  connection  with  the  use  of  extension  apparatus  Bardenheuer^^ 
releases  traction  at  the  end  of  a  few  (four  to  eight)  days  and  employs 
passive  motion  and  massage.  Jordan^^  employs  the  same  measures 
immediately  after  the  fracture  is  reduced,  loosening  or  removing  the 
apparatus  daily  for  the  purpose.  Most  surgeons,  including  the  writer, 
do  not  recognize  the  need  of  such  precipitate  activities  in  this  conn'ec- 
tion,  on  the  ground  that  early  manipulations  must  of  necessity  be 
attended  with  pain  and  that  the  immobilization  of  fracture  (even  those 
involving  a  joint)  for  one  week  cannot  possibly  be  harmful.  On  the 
contrary,  the  enforced  rest  of  the  part  unquestionably  protects  the 
zone  of  injury  from  additional  trauma  (such  as  renewed  subcutaneous 
bleeding),  and  presents  conditions  favorable  to  the  establishment  of 
regenerative  processes. 

Massage  is  directed  from  the  periphery  toward  the  body  and  should 
not  be  prolonged  more  than  twenty  or  thirty  minutes,  nor  should  it 
be  forcibly  employed  (Jordan-^).  When  abrasions  or  wounds  are 
present  the  manipulations  must  be  postponed  until  healing  has  taken 
place.  Neither  passive  nor  active  motion  should  cause  pain.  During 
the  manipulations  the  part  should  be  postured  and  supported  by  an 
assistant  so  that  the  proper  alignment  of  the  fragments  is  not  dis- 
turbed. 

In  cases  of  typical  fracture  (such  as  Colles'  or  Pott's)  the  part  may 
be  immobilized  so  that  restricted  motion  may  he  executed  in  a  manner 
which  does  not  disturb  the  fragments  (Lexer,^*  v.  Bergmann,^* 
Krantz^"'). 

The  period  of  disability  following  fractures  is  markedly  reduced 
by  the  judicious  combination  of  massage  and  immohilization.  The  aim 
should  be  to  attain  restoration  of  function  simultaneously  with  firm 
bony  union.  When  prolonged  immobilization  is  employed  the  problem 
of  restoration  of  function  becomes  unnecessarily  complicated  and  pro- 
tracted. 

In  practice,  the  ideal  procedure  is  to  arrange  the  gypsum  dressing 
in  such  a  manner  that  it  is  easily  removed  {which  should  he  done 
three  times  a  week),  the  part  massaged,  the  joints  carefully  moved, 
and  the  dressing  reapplied.  When  firm  union  is  established,  massage 
and  passive  motion  may  be  supplemented  by  warm  baths  and  active 
motion,  the  latter  being  executed  under  the  guidance  of  the  attendant 


INJURIES  TO  THE  OSSEOUS  SYSTEM  663 

with  the  view  of  encouraging  efforts  consistent  with  the  normal  mo- 
tility of  the  part. 

The  second  factor  which  interferes  with  the  return  of  function  is 
union  of  a  fracture  in  a  faulty  position,  the  result  of  incomplete  re- 
duction of  the  deformity  or  failure  to  maintain  the  fragments  in  proper 
position  after  reduction  has  been  effected.  However,  union  in  a 
faulty  position  does  not  always  mean  appreciable  interference  with 
function,  a  fact  borne  out  by  X-ray  photographs  taken  after  fractures 
have  healed.  Marked  displacement  of  fragments  which  cause  shorten- 
ing of  the  limb,  deformity  which  interferes  with  the  usefulness  of 
the  part  and  which  lessens  the  range  of  motion  of  joints  possess  sur- 
gical importance. 

Osteoclasis,  or  refracture  of  a  bone,  is  employed  in  cases  in  which 
the  faulty  position  is  due  to  improper  reduction  or  lack  of  effective 
immobilization,  and  when  it  is  feasible  to  place  the  thus  artificially 
separated  fragments  in  normal  relationship  to  each  other.  That  is  to 
sa}',  the  procedure  should  not  be  attempted  unless  there  is  reasonable 
certainty  that  the  desired  end  may  be  accomplished.  In  comparatively 
recent  cases,  refracture  may  be  accomplished  with  the  hands,  by  bend- 
ing the  bone  over  the  knee  or  the  edge  of  the  table.  In  old  cases  the 
use  of  apparatus  is  advisable;  for  the  purpose  special  instruments, 
called  osteoclasts,  have  been  devised.  In  difficult  cases  the  desired 
end  is  attained  by  means  of  pulleys  which  graduallj^  bend  the  peri- 
pheral portion  of  the  limb  to  the  necessary  extent.  In  most  cases  the 
prolonged  shortening  of  the  limb  has  caused  the  muscles  to  contract  so 
that  temporary  extension  and  counterextension  must  be  employed  be- 
fore maintenance  of  the  limb  in  the  corrected  position  is  feasible. 

The  open  reduction  of  fractures  was  first  practiced  in  connection 
with  the  treatment  of  non-union  {pseudarthrosis)  and  in  old  cases  of 
union  with  much  displacement  of  the  fragments  and  subsequent  de- 
formity. The  site  of  the  fracture  is  exposed,  the  connective  tissue 
bridge  is  dissected  out  or,  when  faulty  bony  union  is  present,  the 
fragments  are  separated  with  the  chisel  and  mallet,  the  ends  of  the 
fragmeyits  refreshed  and  held  in  apposition  by  means  of  sutures, 
nails,  plates,  etc.  (see  below).  In  some  cases  function  is  interfered 
with  by  the  presence  of  projecting  splinters  of  bone,  in  which  event, 
their  simple  removal  is  all  that  is  necessary. 

In  fresh  fractures  operative  coaptation  is  employed  wnen  the  frag- 
ments are  widely  separated  by  muscular  contraction,  as  in  fracture 
of  the  patella,  the  olecrarion,  and  os  calcis.    In  cases  of  this  sort  oper- 


664.     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

ative  repair  is  followed  by  rapid  and  complete  return  of  function. 
However,  the  advent  of  reliable  asepsis  lias  encouraged  the  employ- 
ment of  the  open  method  of  reduction  of  fractures  and  retention  of  the 
fragments  in  normal  alignment  by  means  of  wire,  plates,  hone  grafts, 
etc.,  in  cases  where  return  of  function  following  the  injury  was,  to  say 
the  least,  a  matter  of  doubt. 

Operative  efforts  at  relief  (the  so-called  open  method)  in  connec- 
tion wuth  fractures  should  not  be  indiscriminately  employed.  When 
indicated  and  properly  executed,  its  achievements  may  be  regarded  as 
brilliant,  Koenig^,  who  has  made  an  exhaustive  study  of  the  question, 
considers  the  procedure  justifiahle  in  cases  of  fracture  of  the  shafts  of 
the  humerus  and  femur  with  marked  displacement  and  the  interposi- 
tion of  muscle;  in  isolated  fractures  of  the  radius  and  ulna  (to  pre- 
vent s^'nostosis)  ;  in  cases  of  multiple  fracture;  in  avulsion  fractures 
(when  the  insertion  of  important  muscles  are  avulsed)  ;  in  fractures 
involving  joints  with  rotation  of  the  fragment ;  in  fracture  disloca- 
tions; in  intrascapsular  fracture  of  the  neck  of  the  femur;  and  in 
cases  of  comminution  of  epiphyses,  the  resection  of  which  is  necessary. 

One  week  after  the  occurrence  of  the  fracture  is  the  hest  time  for 
making  operative  efforts  at  relief  (Koenig').  At  this  time  the  re- 
generative processes  have  begun  and  the  effused  blood  has  established 
circulatory  connection  with  the  surrounding  soft  parts.  Earlier  oper- 
ation robs  the  natural  processes  of  repair  of  the  stimulus  caused  by 
the  presence  of  exudate,  delays  the  formation  of  callus,  and  favors 
the  formation  of  a  false  joint. 

The  technic  of  operative  apposition  of  fragments  consists  of  pre- 
liminary exsanguination  of  the  part  by  the  v.  Esmarch  bandage,  ex- 
posure of  the  seat  of  fracture,  alignment  of  the  fragments  and  their 
retention  in  the  corrected  position  by  various  means  (Part.  IV, 
chap.  vi). 

After  the  soft  parts  are  closed,  the  fractures  are  treated-  in  the 
same  way  as  are  subcutaneous  fractures,  i.  e.,  b}^  a  judicious  combi- 
nation of  immobilization,  massage,  and  passive  motion. 

The  treatment  of  delayed  callus  formation  consists  of  the  correc- 
tion of  constitutional  causes  and  the  local  use  of  irritants.  For  the 
latter  purpose  injections  of  alcohol,  turpentine,  tincture  of  iodin, 
chlorid  of  zinc,  and  lactic  acid  have  been  used.  Helfrich^  advises 
the  use  of  passive  hyperemia  from  two  to  three  hours  daily.  The  em- 
ployment of  ambulatory  " semifixation"  apparatus  has  been  fol- 
lowed by  success  in  connection  with  fractures  of  the  leg  and  thigh. 


INJURIES  TO  THE  OSSEOUS  SYSTEM  665 

SasakP*  claims  good  results  following  the  injection  of  an  emulsion  of 
periosteum.  None  of  these  methods  is  universally  successful  and  all 
of  them  require  the  exercise  of  great  patience  and  persistence.  When 
it  is  manifest  that  the  formation  of  callus  is  delayed,  the  open  opera- 
tion is  likely  to  be  followed  by  more  rapid  results. 

In  cases  in  which  resection  of  the  pseudarthrosis  leaves  a  space  he- 
tween  the  fragments,  osteoplastic  repair  may  he  practiced.  This  com- 
paratively modern  method  of  procedure  is  preferable  to  the  older  one 
of  shortening  the  limb  by  bringing  the  fragments  in  contact  with 
each  other  which,  in  the  leg  or  forearm,  necessitates  resection  of  a 
portion  of  the  contiguous  bone  (v,  Bergmann-^).  The  plastic  repair 
is  accomplished  by  the  transplantation  of  a  fresh  autogenous  hone 
graft,  together  with  its  periosteum,  and  may  be  executed  with  a  simi- 
lar graft  derived  from  a  freshly  amputated  limb  (p.  802)  ;  the  former 
is  preferable.  A  medullary  inlay  of  fresh  bone  (p.  805),  horn  or 
ivory  may  be  used.  The  use  of  a  pediculated  skin — periosteal — bone 
flap  derived  from  the  immediate  vicinity  of  the  injury  gives  excellent 
results,  involving  as  it  does  the  basic  principles  of  plastic  repair  essen- 
tial to  success  (W.  Miiller,-'^  v.  Eiselsberg-*).  In  fractures  of  the 
tibia,  ReicheP^  uses  a  bone  graft  taken  from  the  tibia  of  the  other 
leg.  The  technic  of  bone  tran^lantation  in  cases  of  this  sort  has 
been  perfected  to  an  astonishing  extent  by  the  work  of  Albee.^° 

In  cases  of  pseudarthrosis  not  amenable  to  plastic  repair  the  use  of 
apparatus  which  holds  the  part  in  place,  and  permits  of  limited  func- 
tion, must  be  resorted  to. 

OPEN  INJUKIES  OF  BONE  AND  CARTILAGE 

"Wounds  of  all  kinds  may  involve  the  underlj'ing  bones  or  cartilage. 
Injury  of  the  periosteum  and  perichondrium  occurs  in  connection  with 
incised  wounds,  such  as  saber  cuts  or  suicidal  wounds  of  the  larynx ; 
these  tissues  are  also  more  or  less  traumatized  when  the  various  parts 
of  the  body  are  subjected  to  blunt  force.  Injuries  of  this  sort  do  not 
possess  the  same  surgical  significance  as  obtains  w^hen  hone  or  cartilage 
is  injured.  Wounds  of  cartilage. occur  as  a  part  of  injuries  to  the  nose, 
ears  and  costal  cartilages,  though  these  also  do  not  involve  the  great 
menace  coincident  to  open  injuries  of  bones  {compound  fractures) 
which,  because  of  the  danger  of  infection  and  the  trauma  to  soft  parts 
that  usually  attends  their  infection,  present  one  of  the  gravest  prob- 
lems confronting  the  surgeon.  The  menace  involved  in  this  class  of 
cases  lies  not  so  much  in  the  form  and  extent  of  the  fracture  as  in  the 


666     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

character  and  extent  of  the  wound.  In  some  instances  the  wound, 
which  establishes  a  communication  with  the  site  of  fracture  may  be  so 
slight  that  the  clinical  course  of  the  case  does  not  differ  in  any  essen- 
tial regard  from  that  of  an  ordinary  subcutaneous  fracture;  on  the 
other  hand,  the  soft  parts  may  be  so  extensively  contused  and  lacer- 
ated that,  irrespective  of  the  bone  injury,  amputation  becomes  neces- 
sary. 

Compound  fractures  are  caused  hy  direct  external  violence  which 
first  penetrates  the  soft  parts  and  then  breaks  the  bone,  or  by  indirect 
force  from  within  which  causes  the  broken  bone  to  protrude  through 
the  soft  parts.  The  latter  form  may  result  from  the  displacement  of 
the  fragments  which  attends  the  occurrence  of  fracture  or  may  be  due 
to  ma7iipulations  which  follow  after  the  bone  is  broken  (transporta- 
tion, faulty  handling,  struggling  during  narcosis,  etc).  At  times 
simple  fracture  becomes  compound  by  the  pressure  of  immobilization 
apparatus  which  causes  sloughing  of  the  soft  parts  in  contact  with  the 
sharp  edge  of  a  fragment.  Fractures  of  the  nasal  bones  and  of  the 
base  of  the  skull  are  frequently  compound  as  the  result  of  laceration 
of  mucous  membranes. 

Operative  compound  fractures  are  produced  by  the  surgeon  in 
connection  with  various  procedures,  such  as  temporary  section  of  the 
inferior  maxilla  for  carcinoma  of  the  mouth;  osteoplastic  section  of 
the  skull  preliminary  to  surgical  attack  upon  the  cranial  contents; 
osteotomy  for  the  correction  of  congejiital  or  acquired  deformity,  etc. 

Compound  fractures  caused  by  projectiles  receive  special  attention 
(Part  IV,  chap.  viii).  Technically  the  division  of  bones  in  connection 
with  traumatic  or  surgical  amputations  should  also  be  regarded  as 
compound  fractures. 

The  examination  and  diagnosis  of  compound  fractures  are  governed 
by  the  same  rules  as  apply  to  simple  fractures.  Digital  examination 
and  probing  of  a  compound  fracture  is  a  surgical  blunder. 

A  discussion  of  the  treatment  of  compound  fractures  may  be  pre- 
faced by  quoting  the  expression  of  v.  Volkmann^^  who  in  1877  said 
"The  application  of  the  first  dressing  decides  the  fate  of  the  patient 
and  the  clinical  course  of  the  wound."  However,  the  practice  of  that 
period,  which  consisted  of  wide  exposure  of  the  seat  of  fracture  and 
lavage  of  the  wound  with  disinfecting  solutions  in  all  cases,  has  been 
abandoned  since  v.  Bergmann^^  showed  that  a  number  of  fractures 
which  communicate  with  the  outer  world  through  small  wounds 
promptly  heal  when  wide  exposure  and  lavage  are  omitted. 


INJURIES  TO  THE  OSSEOUS  SYSTEM  667 

In  the  severe  cases  in  which  the  presence  of  infectiaji  may  he 
assumed,  the  principles  of  first  aid  and  temporary  hemostasis  should 
be  observed.  The  greatest  simplicity  of  action  should  be  followed. 
Clothing  should  be  removed;  the  wound  should  be  covered  with 
sterile  or  freshly  laundered  fabric ;  and,  when  bleeding  is  profuse,  a 
tourniquet  should  be  applied,  and  the  part  immohilized  ivithout  any 
effart  at  reduction  of  the  fracture.  Meddlesome  palpation,  wiping, 
and  lavage  of  the  wound  must  be  avoided.  Conformation  to  this 
warning  will  often  obviate  the  development  of  putrefactive  and  pyo- 
genic infection,  purulent  arthritis,  and  tetanus. 

When  the  patient  is  transported  to  an  environment  in  which  asepsis 
is  available,  he  is  placed  on  the  operating  table,  the  first  aid  dressing 
is  removed,  the  part  steadied  by  an  assistant,  and  the  narcotic  state  is 
produced.  The  wound  is  covered  with  sterile  gauze  and  the  entire 
part  cleansed  and  disinfected.  Gross  particles  of  dirt  and  other 
foreigh  (Substances  are  removed  with  forceps.  Lavage  of  the  wound 
with  an  antiseptic  solution  or  with  physiological  salt  solution  and  the 
use  of  strong  disinfectants  (such  as  alcohol  and  iodin)  in  the  wound 
must  be  avoided.  Three  per  cent  hydrogen  peroxid  may  be  gently 
dripped  into  the  w^ound,  the  foam  of  which  mechanically  removes  in- 
fective material  and  does  no  harm  to  the  tissues. 
•  The  succeeding  steps  of  the  procedure  depend  upon  the  character 
of  the  wound  and  the  severity  of  the  injury. 

When  a  small  wound  is  produced  by  the  protrusion  of  the  edge  of 
one  of  the  fragments  (perforation  compound  fracture),  the  coagulated 
blood  is  gently  expressed  through  the  opening  of  the  skin  by  means 
of  two  sterile  gauze  wipes,  a  procedure  which  also  expels  foreign  sub- 
stances; and  the  fracture  is  reduced  and  covered  {not  packed)  with 
iodoform  gauze  which  converts  the  injury  into  a  subcutaneous  frac- 
ture. The  part  is  then  embedded  in  sterile  gauze  and  immohilized  in 
gypsum.  The  latter  is  preferable  to  an  extension  apparatus  until 
granulation  has  been  established,  since  ahsolute  rest  of  the  part  is 
essential  to  uncomplicated  wound  repair^  Operative  reductioyi  of 
deformity  should  never  he  attempted  until  the  wound  in  the  soft  parts 
is  healed  (usually  at  the  end  of  the  second  or  third  week) . 

When  the  end  of  a  fragment  protrudes  from  the  wound,  it  should 
be  cleansed  as  stated  above  before  reduction  is  made.  In  cases  in 
which  dirt  or  other  foreign  material  is  embedded  in  the  bone  it  is 
better  to  resect  a  small  portion  than  to  reduce  an  unclean  fragment. 

When  a  large  wound  is  present,  the  skin  widely  undermined,  the 


668     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

muscles  and  other  soft  parts  extensively  crushed  and  torn,  and  the 
bone  comminuted,  the  wound  should  he  enlarged  if  necessary  and  held 
apart  with  retractors  while  fragments  of  tissue  and  splinters  of  bone 
are  removed;  spurting  blood  vessels  are  deligated  and  torn  tendons 
and  nerves  repaired.  The  fragments  are  placed  in  proper  alignment, 
using  sutures,  nails,  etc.,  for  the  purpose  when  the  deformity  has  a 
tendency  to  recur.  In  cases  of  this  sort  provision  for  counter  drain- 
age should  be  made.  After  the  mechanical  cleansing  of  the  wound  is 
accomplished  it  should  be  loosely  packed  with  iodoform  gauze  with 
the  view  of  removing  retained  infectious  elements  and  wound  secre- 
tions by  means  of  suction.  A  gypsum  dressing  (circular)  provided 
with  an  appropriate  fenestrum  should  be  applied  at  once.  This  holds 
the  parts  quiescent,  permits  of  early  inspection  of  the  wound,  and 
allows  of  secondary  repair  by  suture  when  infection  has  been  avoided, 
or  of  the  employment  of  additional  drainage  when  the  immediate 
outcome  is  less  fortunate. 

Primary  suture  of  the  entire  wound  favors  retention  of  pyogenic 
excitants  and  creates  conditions  favorable  to  the  conversion  of  mod- 
erate infection  into  a  seriously  menacing  one;  it  should,  therefore,  not 
he  employed  under  any  circumstances. 

In  cases  attended  with  severe  crushing  of  the  soft  parts,  immediate 
amputation  must,  at  times,  be  resorted  to.  This  is  chiefly  determined 
by  the  failure  of  circulation  in  the  part  distal  to  the  injury  as  shown 
by  absence  of  pulsation ;  however,  the  main  blood  supply  of  a  limb 
may  be  intact  and  yet  the  soft  parts  be  so  extensively  crushed  that 
necrosis  is  certain  and  prompt  amputation  is  indicated. 

Complete  avulsion  of  a  limh  calls  for  ligature  of  the  large  blood 
vessels  and  removal  of  protruding  bone  to  the  extent  necessary  to  the 
formation  of  a  proper  stump.  At  the  fingers  and  toes  it  is  at  times 
justifiable  to  leave  the  denuded  portion  of  a  phalanx  and  cover  the 
exposed  bone  by  skin  grafting. 

Compound  fractures  coming  under  observation  after  the  lapse  of 
several  days,  when  infection  is  already  established,  require  incision  of 
phlegmonous  areas,  and  gouging  out  or  resection  of  infected  frag- 
ments, removal  of  gangrenous  tissues,  and,  when  the  infection  is 
severe,  may  demand  amputation. 

Efforts  at  reestahlishment  of  function  must  be  postponed  until 
infection  has  suhsided  or,  in  clean  cases,  until  healthy  granulation  has 
developed.  The  methods  employed  in  this  connection  do  not  differ 
from  those  used  in  cases  of  simple  fracture. 


INJURIES  TO  THE  OSSEOUS  SYSTEM  669 

BIBLIOGRAPHY 

1.  Helferich.     Atlas  d.  traum.  Fract.,  etc.,  Miinch.,  1914. 

2.  CoDMAN.     See  Scudder,  No.  9. 

3.  RiBBERT.     Deutsch.  med.  Woeh.,  1900. 

4.  J.  Wolf.     Leipzig,  1901. 

5.  Zondek.     Berlin,  1910. 

6.  Frangenheim.     Arch.  f.  klin.  Chir.  Ixxx,  1906. 

7.  Fritz  Koxig.     Arch.  f.  klin.  Chir.  Ixxx,  1906. 

8.  Beely.    Ivonigsberg,  1878. 

9.  Scudder.     The  Treat,  of  Fract.,  Phila.  and  London. 

10.  Thomas.     Same  as  No.  9. 

11.  V.  Bruns.     Deutsch.  Chir.,  Stuttgart,  1886,  with  lit. 

12.  Albers,  v.  Bardeleben  and  Korsch.     Chir.  kong.  Verh.,  1894,  ii. 

13.  V.  Eiselsberg.     Chir,  kong.  Verh.,  1897,  ii. 

14.  Lexer.    Miinch.  med.  Woch.,  1909. 

15.  Buck.     Quoted  by  v.  Volkmann,  in  v.  Pitha-Billroth  Haudb.  d.  Chir. 

16.  Bardenheuer.     Stuttgart,  1890. 

17.  Blake.     Fractures,  D.  Api:)leton  &  Co.,  N.  Y.  and  London,  1919. 

18.  Sinclair.     Brit.  Med.  Jr.,  Aug.  26,  1916. 

19.  ZuppiNGER  and  Christen.     Leipzig,  1913. 

20.  Codevilla.     Zeitschr.  f .  orth.  Chir.  Bd.  27,  1910. 

21.  Steinmann.     Neue  deutsch.  Chir.  Bd.  i,  1912. 

22.  Championniere.     Quoted  by  Lexer,  Allg.  Chir.  i,  Stuttgart,  1914. 

23.  Jordan.    Miinch.  med.  Woch.,  1903. 

24.  V.  Bergmann.     Beitr.  z.  klin.  Chir.  Bd.  71,  1911. 

25.  Krantz.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  106,  1910. 

26.  Sasaki.    Deutsch.  Zeitschr.  f.  Chir.  Bd.  109,  1911. 

27.  W.  MiJLLER.     Samml.  klin.  Vort.,  No.  145. 

28.  V.  Eiselsberg.    Chir.  kong.  Verh.,  1897. 

29.  Reichel.     Chir.  kong.  Verh.,  1903,  ii. 

30.  Albee.     Bone  Graft  Surg.,  Saunders,  Phila.  and  London,  1915. 

31.  V.  Volkmann.     Samml.  klin.  Vort.,  1871,  Nos.  117-118. 

32.  V.  Bergmann.    Erste  artz.  Hilfe,  Berlin,  1903. 


CHAPTER  V 


SPECIAL   FRACTURES 


FRACTURES  OF  THE  BONES  OF  THE  FACE 

The  bones  of  the  face  are  so  readily  accessible  to  examination  from 
without  and  through  the  cavities  of  the  face  that  the  diagnosis  of 
fracture  is  not  fraught  with  difficulties.     As  the  site  of  a  fracture  in 

this  location  usually  com- 
municates with  the  nasal  or 
oral  cavities,  it  is  often  com- 
pound ;  however,  infection 
rarely  occurs.  Of  all  frac- 
tures, those  of  the  bones  of 
the  face  comprise  about  2.8 
per  cent. 

Fracture  of  Nasal  Bones. — • 
The    nasal    hones   are   frac- 
tured   by    direct    violence ; 
usualh'  by  a  fall  or  a  blow. 
The   lesion    is   likely   to   be 
attended    with    deformity 
(traumatic  saddle  nose)  and 
with  more  or  less  injury  to 
the  deeper  soft   parts.     In 
fresh    cases    the    depressed 
bones  are  easily  elevated  by 
means  of  a  blunt  instrument 
introduced    into   the   nares. 
As    a    rule,    the    injury    is 
recognized  by  bleeding,  suggillation,  and  more  or  less  emphysema  of  the 
skin.   The  last  is  due  to  the  entrance  of  air  through  a  tear  in  the  mucosa. 
Fracture  of  Malar  Bone. —  Fractures  of  the  malar  tone  and  superior 
maxilla  are  due  to  direct  violence  and  are  often  complicated  bj^  a 

670 


Fig.  232. —  Muscles  Responsible  tor  Mal- 
position IN  Fracture  Through  the  Body 
OF  the  Lower  Jaw. 


SPECIAL  FRACTURES 


671 


wound  of  the  overlying  soft  parts.  The  diagnosis  is  easily  made  by 
mspection  and  palpation.  Reposition  of  displaced  alveolar  processes 
is  best  accomplished  by  the  dentist.  However,  the  surgeon  may  find 
it  advisable  to  fix  the  fragment  in  place  by  wiring,  nailing,  etc. 
(p.  789).  During  repair  the  mouth  must  be  kept  clean.  For  the 
purpose  frequent  lavage  with  large  quantities  of  sterile  fluid  may 
be  used. 

Fractures  of  the  Mandible. —  Fractures  of  the  lower  jaw  are  not 
infrequent.  The  diagnosis  is  based  on  the  faulty  alignment  of  the 
teeth  and  the  visible  and  palpable  deformation  of  the  jaw.  Fractures 
of  the  body  present  a  typical  deformity ;  the  posterior  half  of  a  side 
is  pulled  upward  by  the  masseter  muscle,  the  anterior,  is  drawn  down- 
ward by  the  digastric  and  other  muscles  attached  to  the  chin.     Mod- 


A  B 

Fig.  233. —  A,  Hammond's  Wire  Splint  tor  Fracture  of  the  Lower  Jaw; 

B,  Splint  in  Place. 


erate  inward  displacement  is  caused  by  the  action  of  the  pterygoids. 
The  inward  displacement  is  evinced  b}'  the  narrowing  of  the  arc  of 
the  maxillary  body.     Double  and  comminuted  fractures  are  not  rare. 

The  causation  of  fracture  of  the  lower  jaw  is  almost  limited  to  direct 
violence  (a  blow).  However,  it  may  be  caused  by  indirect  violence, 
such  as  a  fall  on  the  chin  or  lateral  compression  of  the  bone.  Frac- 
tures (avulsion)  of  the  alveolar  processes  are  often  produced  during 
the  extraction  of  a  tooth. 

In  the  treatment  of  fractures  of  the  lower  jaw  it  is  necessary  to 
remember  that  the  laceration  of  the  mucosa  makes  these  compound,  and 
that  cleansing  of  the  mouth,  especially  after  eating,  is  of  great 
importance. 

Reposition  of  the  displaced  fragments  usually  is  easilj^  accomplished 


672     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

by  pressure;  however,  retention  in  the  corrected  position  is  not  without 
its  difficulties.  Fortunately,  the  older  methods  of  fixation,  by  means 
of  splints,  bandages,  etc.,  are  no  longer  necessary.  The  dentist  is  able 
to  hold  the  fragments  in  place  by  means  ,of  splints  fastened  to  the 
teeth.  In  not  a  few  cases,  simple  wiring  of  the  teeth  suffices  for  the 
purpose.  A  useful  method  of  fixation  is  shown  in  Fig.  233.  Exposure 
of  the  fracture  and  fixation  by  means  of  wire,  after  drilling  the  frag- 
ments, is  indicated  when  the  teeth  are  absent.  The  writer  has  seen 
excellent  results  following  wiring  of  the  teeth  of  both  fragments  of 
the  lower  jaw  to  those  of  the  upper.  During  healing  the  patient  is 
nourished  with  liquid  food. 

The  articular  process  of  the  lower  jaw  is  occasionally  fractured. 
Avulsion  of  the  coroiiaid  process  from  violent  tension  upon  the  tendon 
of  the  temporal  muscle  has  occurred  ;  it  is  followed  hy  wide  separation. 

FRACTUEES  AND  DISLOCATIONS  OF  THE  VERTEBRAL  COLUMN 

Fractures  and  dislocations  of  the  vertebrae  have  so  much  in  common 
and  coexist  so  frequently  that  it  would  seem  proper  to  consider  them 
together. 

FRACTURES  OF  THE  VERTEBRAL  COLUMN 

Fractures  of  the  Bodies  of  the  Vertebrae. —  Fractures  of  the  bodies  of 
the  vertebra  occur  most  frequently  in  the  region  of  the  fifth  and  sixth 
cervical,  the  lower  dorsal,  and  the  upper  lumbar  regions.  They  are 
usually  produced  by  great  violence,  which  is  understandable  when  the 
great  resistance  and  the  elasticity  of  the  bones,  together  with  the  fact 
that  one  fourth  the  entire  length  of  the  spinal  column  consists  of  inter- 
vertebral discs,  is  taken  into  account.  The  motility  of  the  spinal 
column  is  shown  by  the  antics  of  the,  so-called,  "rubber  men"  who,  as 
the  result  of  practice,  are  capable  of  astonishing  deformations  in  the 
cervical  region,  at  the  junction  of  the  dorsal  and  lumbar,  and  in  the 
lumbar  vertebrae  themselves ;  these  are  also  the  locations  where  frac- 
tures usually  occur,  because  it  is  here  that  the  greatest  degree  of  motion 
is  possible.  The  spinal  column  may  be  compared  to  a  rod  of  varying 
elasticity  which,  when  bent,  breaks  at  the  junction  of  an  elastic  portion 
with  a  more  rigid  one.  In  the  spinal  column  these  points  are  in  the 
region  of  the  twelfth  dorsal  and  the  first  lumbar  vertebra  and,  more 
especially,  in  the  lower  cervical  region  in  which  comparatively  slight 
trauma  causes  fracture. 

Direct  violence  is  rarely  responsible  for  fracture  of  the  vertebral 


SPECIAL  FRACTURES  673 

bodies.  Even  in  fractures  following  a  severe  blow  or  when  the  patient 
is  "run  over,"  the  influence  of  indirect  violence  is  not  readily  excluded. 

Indirect  violence  is  usually  expended  upon  the  bodies  of  the  vertebrge. 
They  are  fractured  during  exaggerated  flexion  of  the  spinal  column, 
by  compression,  or  by  sliding  force,  or  by  a  combination  of  these  three 
factors.  The  fracture  is  produced  b}^  great  force  (a  fall  upon  the 
back,  the  head,  the  buttocks  or  the  feet),  while  the  musculature  holds 
the  spinal  column  rigid.  Not  rarely  the  injury  is  produced  in  miners 
by  the  impact  of  heavy  bodies,  such  as  coal  or  iron  ore,  striking  the 
patient  on  the  back  of  the  neck.  The  impact  flexes  the  spine  and  pro- 
duces the  fracture  by  indirect  violence.  Compression  fractures  in  the 
cervical  region  are  also  produced  by  forcible  flexion  of  the  head ;  the 
chin  touches  the  sternum  which,  not  infrequently,  is  simultaneously 
fractured.  A  similar  condition  of  affairs  occurs  when  the  flexed  body 
is  caught  between  the  arch  of  a  doorway  and  the  top  of  a  moving 
wagon.  Fracture  of  the  fifth  lumbar  vertebra  occurs  in  persons  who 
make  a  misstep  while  carrying  a  heavy  weight  upon  the  head  and 
shoulders. 

Fractures  of  the  vertebral  bodies  are  classified  as : 

Oblique,  which  are  attended  with  much  displacement.  The  line  of 
fracture  usually  runs  from  above  and  behind  to  below  and  in  front. 
Longitudinal  fractures  are  very  rare. 

Transverse,  occur  in  connection  with,  so-called,  compression  or  crush- 
ing fractures.  They  are  produced  by  maximum  flexion  and  simulta- 
neous compression  of  the  spinal  column  in  its  longitudinal  axis.  In 
this  way  the  less  resisting  vertebral  body  is  crushed  by  its  neighbors 
and  is  spread  in  its  transverse  diameter  and  shortened  in  the  longi- 
tudinal. Actual  impaction,  infraction,  and  fissuring  may  occur. 
Although  a  gross  disturbance  of  the  outline  of  the  spinal  column  may 
not  occur,  severe  trauma  of  the  spinal  cord  is  very  likely  to  attend 
the  injury.  Laceration  and  partial  or  complete  avulsion  of  the  inter- 
vertebral discs  are  also  liable  to  occur.  In  twenty-three  cases  of 
compression  fracture  of  the  vertebral  bodies,  Koclier^  found  sixteen 
in  the  dorsal,  seven  in  tlie  lumbar,  and  none  in  the  cervical  vertebrae. 

Symptoms. —  Aside  from  shod',  which  is  always  severe,  the  appear- 
ance of  a  traumatic  JiijpJws  at  the  site  of  the  fracture  is  of  importance. 
The  kj'phos  is  caused  by  the  displacement  of  the  fragments  in  the  sense 
of  a  shortening  of  the  entire  spinal  column.  It  is  especially  notice- 
able when  the  patient  sits  up,  the  effort  at  relieving  the  pressure  and 
the  drag  of  the  musculature,  causing  the  spinous  process  at  the  site 


674    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


of  the  injury  to  become  prominent.     In  oblique  fractures  a  lateral 
displacement  may  also  take  place. 

The  complications  relate  to  injury  of  the  spinal  cord  and  spinal 
nerves.  Although  the  cord  is  well  protected  by  the  bouy  arches,  the 
dura  mater,  and  the  cerebrospinal  fluid,  fracture  of  the  vertebral 
bodies  with  displacement  of  the  fragments  is  likely  to  be  attended 
with  crushing  of  the  cord.  Localiza- 
tion of  the  injury  to  the  cord  is  taken 
up  in  Part  IX,  chap.  iv. 

The  diagnosis  of  fracture  of  the 
body  of  the  vertebra,  in  severe  cases, 
is  selfevident.  When  the  character  of 
the  injury,  the  kyphos,  and  the  evi- 
dences of  crushing  of  the  cord  are 
present,  there  is  no  doubt  as  to  the 
diagnosis.  However,  the  presence  of 
nervous  s^Tuptoms  is  not  essential  to 
the  diagnosis.  It  is  to  be  noted  that 
many  cases  of  fracture  of  the  bodies 
of  the  vertehrce  are  not  attended  with 
lesions  of  the  spinal  cord.  Of  forty- 
seven  cases  collected  by  Quetsch,^ 
nineteen  gave  evidence  of  involvement 
of  the  cord;  in  the  final  analysis,  the 
symptoms  in  sixteen  cases  proved 
transitory,  and  in  three  instances 
only  were  they  permanent  (Frazier^). 
Fig.  235  shows  a  case  in  which  the 
cord  was  not  injured.  In  these 
cases  the  causative  trauma  is  slight 
and  the  kyphos  is  moderate  in  degree, 
by  careful  inspection 


Tig.  234. —  Fracture  in  the 
Eegion  of  the  Bodies  of 
THE  Sixth  and  Seventh 
Cervical  Vertebrae  with 
Pressure  on  the  Cord. 


The  kyphos  is  only  discovered 
Localized  pressure  often  produces  pain.  Pain 
at  the  site  of  the  fracture  may  be  produced  by  jarring  pressure  on  the 
head.  The  fact  that  the  patient  is  able  to  walk  and  to  perform  light 
labor  does  not  exclude  fracture  (especially  compression  fracture). 
Belated  symptoms  indicate  pressure  from  callus  masses  or  dissociation 
of  the  fragments  (after  impaction).  So-called  traumatic  spondylitis 
belongs  to  this  class  of  cases  in  which  the  X-ray  often  reveals  an  old 
compression  fracture. 

The  X-ray  picture  is  of  great  help  in  the  diagnosis  of  fractures  of 


SPECIAL  FRACTURES 


675 


the  vertebrse.  However,  positive  findings  are  only  available  when  the 
technic  of  the  exposure  is  in  the  hands  of  expert  operators  and  when 
the  negatives  are  read  by  experienced  Rontgenologists. 

The  prognosis  of  fractures  of  this  sort 
depends  upon  the  character  of  the  associ- 
ated lesions  and  their  sequelae.  The  frac- 
ture of  itself  is  capable  of  bony  union  and 
when  no  complications  exist  the  afflicted 
person  is  able  to  go  about  with  but  little 
interference  with  function.  Radiating 
pains,  due  to  pressure  upon  the  nerves  as 
they  pass  through  the  intervertebral  fora- 
mina are  often  observed.  Lesions  of  the 
cord  are  always  portentous  of  serious  after 
effects.  Even  though  mijelitis  does  not  de- 
velop, paralysis  of  the  bladder  means  cathe- 
ter life,  and  this,  despite  the  greatest  care, 
is  followed  by  cystitis,  often  later  by  pye- 
litis and  suppurative  nephritis  and  death. 
Sensanj  paralysis  is  always  attended  with 
trophic  disturbances,  pressure  necrosis,  and 
a  fatal  outcome  ensues  from  exhaustion.  In 
cases  of  this  sort,  intensive  control  of  nurs- 
ing, the  care  of  the  bed  (water  or  air  bed), 
scrupulous  cleanliness,  etc.,  are  essential  to 
the  comfort  of  the  patient  and  have  an 
important  bearing  on  the  prognosis.  In 
hospitals,  special  beds  are  so  constructed 
that  the  necessary  manipulations  may  be 

^    „,  .      ,.       ,    ,  carried  out  with  the  maximum  degree  of 

A,  The  anterior  lip  of  the  .  mi        i  •    i  i 

fifth  dorsal  vertebra  is  forced  comfort  to  the  patient.     The  higher  the 

into  the  sixth;  the  canal  is  injury  of  the  vertebral  column,  the  more 
not  involved;   B,  the  body  of  i  ,      •       i 

the  first  lumbar  vertebra  is  Unfavorable  IS  the  prognosis. 

crushed   and   spread   out,   so  The  treatment  begins  as  soon  as  possible, 

that   the    canal  is   encroached  .„                                                  ,             ,            .^. 

upon ;   the  symptoms  are  re-  All  unnecessary  movements,  such  as  sitting 

stricted  to  tlie  cauda  equina,  up^  qj.  lifting  the  patient,  must  be  avoided 

with  the  view  of  preventing  secondary  displacement  of  the  fragments 
which  may  increase  an  existing  lesion  of  the  cord  or  produce  one.  The 
site  of  the  fracture  itself  does  not  always  demand  attention.  In  frac- 
tures in  the  cer^ical  region,  the  parts  may  be  immobilized  by  the  use  of 


Fig.  235. —  Double  Compres- 
sion Fracture  of  the 
Spinal  Column. 


676     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Glisson's  sling  (Fig.  236).  (For  Bradford  frame,  see  Orthopedic 
Section,  Part  VIII.)  A  similar  device  may  also  be  employed  in  cases 
of  fracture  lower  down ;  however,  the  patient  is  often  more  comfortable 
if  simply-  the  recumbent  position  is  maintained.  In  cases  of  fractures 
without  a  cord  lesion,  the  spine  may  be  immobilized  in  a  gj'psum 
corset  and  the  patient  permitted  to  go  about.  Operative  attack  for 
the  purpose  of  removing  the  pressure  on  the  cord  (laminectomy^)  is 
rarely  indicated,  and  is  of  value  only  w^hen  the  vertebral  arch  pene- 
trates the  cord  from  behind.    See  Part  IX,  chapter  iv. 

In  the  less  severe  cases,  in  which  there  is  no  demonstrable  lesion  of 
the  cord,  great  care  in  manipulation  of  the  patient  should  be  exercised. 
Consolidation  of  the  fracture  and  the  prevention  of  secondary  dis- 
placement demands  complete  rest  for  two  or  three  montlis,  followed 


Fig.  236. 


Glisson's  Sling  and  Extension  in  Cases  of  Fracture 
OF  THE  CER^^CAL  VERTEBRAE  (HelfericlO . 


by  the  use  of  suitable  apparatus  for  a  year  or  more.  The  demands 
upon  the  mechanism  of  a  vertebral  body  in  maintaining  the  erect  posi- 
tion, and  e\Qn  in  the  performance  of  light  work,  are  very  great,  and 
the  genesis  of  new  bone  in  this  situation  is  very  sparse.  Recently  it 
has  been  shown  that  comparatively  slight  injury  of  the  vertebral 
column  is  often  followed  by  secondary  changes  (traumatic  spondylitis) 
which  are  attended  with  serious  disturbances  (Fig.  237). 

Fractures  of  the  Vertebral  Arches  or  the  Processes. —  The  rarity  of 
these  fractures  seems  to  have  been  disproved  by  the  X-ra}'. 

Fracture  of  the  spinous  processes,  like  that  of  the  arch,  is  usually 
the  result  of  direct  violence;  however,  extreme  muscular  exertion  may 
be  the  causative  factor  (Schulte,*  Kiittner,^  and  others).  Von 
Kryger^  has  shown  experimentally  (on  the  cadaver)  that  fracture  of 


SPECIAL  FKACTURES 


677 


..e  spines  .^o.e....t^.^^r^^^l^-ZX:^<^'- 


„,.^    GT^nx-nVT  TTTS     CKrHMELL'S    DiSEASE) 

Fig.  237.— The  Kyphosis  of  Traumatic  Spo^DYLITIS    ^iXL 

(Frazier). 


678     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

fracture  depends  somewhat  upon  the  character  of  the  injury  and 
whether  it  is  caused  by  direct  or  indirect  violence.  However,  the  most 
common  location  is  in  the  cervical  and  upper  thoracic  regions. 

The  diagnosis  usually  is  not  made  without  the  X-ray. 

The  treatment  is  similar  to  that  of  fracture  of  the  bod}^,  except  that 
immobilization  need  not  exceed  six  weeks.  In  some  cases,  persistent 
pain  and  tenderness  make  resection  of  the  process  necessary. 

Fractures  of  the  vertebral  arches  occur  more  frequently  in  the  cer- 
vical (especially  of  the  atlas  and  axis)  than  in  the  thoracic  and  lumbar 
regions,  as  the  arches  in  the  last  two  are  firmer  and  thicker  and  pro- 
tected by  a  thick  layer  of  muscles.  However,  Quetsch^  reports  three 
cases  of  isolated  fractures  of  the  arches  of  the  lumbar  vertebrge.  The 
fracture  may  be  confined  to  one  arch  or  several  arches  may  be  in- 
volved ;  it  may  be  bilateral  or  unilateral.  Fracture  of  a  single  lamina 
is  rare.  Delbef^  reports  a  case  of  isolated  fracture  of  the  right  lamina 
of  the  axis. 

The  diagnosis  is  only  possible  with  the  X-ray. 

The  treatment  is  similar  to  that  of  fracture  of  the  vertebral  bodies. 
The  immobilization  should  be  maintained  for  about  six  weeks.  The 
indications  for  laminectomy  are  based  on  the  evidence  of  involvement 
of  the  posterior  sectors  of  the  cord. 

Fractures  of  the  transverse  processes,  since  the  advent  of  the  X-ray, 
have  been  found  to  occur  more  frequently  than  was  previously  be- 
lieved. The  first  recorded  case  was  reported  by  Ehrlich*  (1908). 
Ewald**  discovered  four  in  routine  examinations  of  116  backs  and 
collected  25  cases  from  the  literature.  Fractures  of  this  sort  are 
generally  regarded  as  caused  by  indirect  violence ;  though  muscular 
contraction  may  be  responsible  for  the  injury  (Frazier^) .  The  lumbar 
vertebrae  are  most  often  affected. 

The  occurrence  of  radiating  pain,  following  injury  of  the  back, 
should  arouse  suspicion  of  a  fracture  which  may  be  verified  by  the 
X-ray.  Taylor^"  reports  a  case  of  paralysis  of  the  eighth  cervical  and 
first  dorsal  nerves  due  to  this  injury.  The  fragment  was  removed 
without  any  benefit  other  than  cessation  of  muscular  cramps  and  of 
pain.  Kiliani,^^  in  a  case  of  fracture  of  the  transverse  process  of  the 
first  and  second  lumbar  vertebrae,  removed  the  fragments  and  relieved 
severe  pain  of  seven  months'  standing.  As  a  rule,  however,  the 
employment  of  a  gypsum  jacket  for  from  four  to  six  months  meets  the 
indications. 

Fractures  of  the  articular  processes  usually  occur  in  connection  with 


SPECIAL  FRACTURES  679 

other  fractures  or  fracture  dislocations;  isolated  fractures  are  exceed- 
ingly rare.  Frazier,^  in  going  over  the  recent  literature,  finds  but  one 
case.  He  quotes  a  monograph  by  Gurlt/-  who  submits  a  photograph 
of  a  fracture  of  this  sort. 

Fracture  of  the  articular  processes  at  once  exposes  the  vertebrse  to 
dislocation;  it  may  be  unilateral  or  bilateral  and  may  be  caused  by 
overflexion  or  overextension,  i.  e.,  indirect  violence.  Muscular  action 
is  excluded  because  no  muscles  are  attached  to  the  processes.  The 
diagnosis  is  made  by  the  X-ray.  Persistent,  restricted,  neuralgic  pain 
has  some  diagnostic  significance. 

DISLOCATIONS  OF  THE  VERTEBRA 

There  are  undoubtedly  cases  of  pure  luxation  of  the  vertebrse, 
though  most  cases  of  injury  of  the  spine  are  fractures  or  fracture 
dislocations. 

Of  the  dislocations* of  the  vertebrae,  those  of  the  dorsal  and  lumbar 
regions  are  very  rare,  while  those  of  the  neck  occur  more  frequently 
and  are  of  great  clinical  importance. 

Cervical  Luxations. —  Dislocations  of  the  cervical  vertehroe  are  classi- 
fied as  flexion  and  rotation  dislocations.  The  former  occur  during 
forcible  flexion  of  the  head  upon  the  thorax.  Thus  the  posterior  por- 
tions of  the  vertebrae  are  separated,  the  ligaments  are  stretched  and 
torn  (including  those  of  the  articular  processes),  the  upper  vertebra 
slides  for«-ard,  and  the  luxation  is  produced  (Fig.  238). 

The  symptoms  of  dislocation  are  those  ascribable  to  the  malposition 
of  the  vertebrae  and  to  injury  of  the  cord.  Among  the  former  may 
be  included  localized  pain  and  tenderness,  limitation  of  motion  and 
deformity.  Deformity  is  attended  with  a  peculiar  attitude  of  the 
head  and  neck,  b}-  a  disturbance  of  the  alignment  of  the  spinous 
processes  or,  in  unilateral  luxation,  by  the  prominence  of  a  transverse 
process.  In  the  cervical  region,  the  displacement  of  a  cervical  body 
may  be  detected  in  the  pharynx.  The  symptoms  arising  in  connection 
with  injury  to  the  cord  or  the  roots  of  the  nerves  do  not  differ  from 
those  accompanying  fractures  or  fracture  dislocations.  In  a  general 
way,  it  may  be  said  that  unilateral  luxation  of  a  cervical  vertebra  is 
less  likely  to  be  associated  with  irreparable  injury  to  the  cord  than 
are  fractures  and  fracture  dislocations.  The  writer  observed  a  case  of 
unilateral  luxation  of  the  atlas  (without  cord  sjTnptoms)  which  recov- 
ered with  only  moderate  interference  with  flexion  and  extension,  the 


680     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


subject  of  which  earned  his  commission  iu.  the  French  Army    (at 
Verdun)  during  the  "World  War"  four  years  after  the  injury. 

The  differential  diagnosis  between  fractures  and  dislocations  is 
based  on  the  preternatural  immobilit}^  and  the  Rontgenogram.  In 
the  cervical  region  palpation  of  the  malposition  is  of  aid,  as  is  the 
peculiar  attitude  of  the  head. 

Luxation  of  the  occiput  from  the  atlas,  while  rare,  does  occur  (cases 
are  reported  and  anal^'zed  by  Milner,^^ 
Gibson,^*  Malgaigne,^^  Wagner  and 
Stolper,^**  and  others).  As  the  occipito- 
atloid  joint  is  very  firm,  the  force  re- 
quired to  separate  it  is  very  great,  and 
the  injury  is  usually  attended  with 
-fatal  trauma  to  the  cord.  Reposition  is 
possible  and  may  be  achieved  by  trac- 
tion upon  the  head  and  counterpres- 
sure  upon  the  vertebra.  The  procedure 
is  attended  with  considerable  danger. 

Luxation  of  the  atlas  from  the  axis 
is  often  associated  with  fractures  of  the 
odontoid  process.  It  is  usuall^^  the  re- 
sult of  direct  violence,  although  cases 
due  to  muscular  action  have  been  re- 
ported. A  blow  "upon  the  forehead  in 
falling  a  distance,  when  the  force  is 
directed  from  above  downward,  is  the 
usual  mechanism. 

Forward,  haclnvard,  rotary,  bilateral, 
and  lateral  luxations  are  described.  Back- 
ward  dislocation   is   very   exceptional.   ^i«-      238.— Luxation     of     the 
,,,.,,  Ill  Fifth    Cervical    Vertebra 

Malgaigne^''  reports  a  case  observed  by       (Wagner  and  Stolper). 

Melchion  (quoted  by  Frazier^). 

The  most  common  form  of  dislocation  is  the  unilateral,  often  asso- 
ciated with  a  fracture.  Corner^'^  collected  twenty  eases  in  which, 
excluding  two  fatal  cases,  there  was  no  paralysis  at  first,  though  symp- 
toms of  involvement  of  the  cord  followed  later.  The  diagnosis  is  made 
b}''  the  pain  and  the  stiffness  in  the  neck,  by  examination  of  the 
pharynx,  by  the  position  of  the  head,  by  the  displacement  of  the 
transverse  process  of  the  atlas,  and  by  a  skiagraph. 


SPECIAL  FRACTURES 


681 


In  hilateral  dislocation  rotary  movements  are  abolished.  The  skia- 
graphic  study  is  important  and  has  a  bearing  on  the  treatment.  If 
the  odontoid  process  is  broken,  efforts  at  reposition  are  likely  to  result 
in  sudden  death.  A  fixation  apparatus  such  as  is  sho\ATi  in  Fig.  239, 
or  a  gypsum  collar  should  be  worn  for  at  least  three  months,  if  reduc- 
tion succeeds.  In  irreducible  luxations  a  suitable  appliance  should  be 
worn  iudeiinitely.  However,  in  the  case  observed  b}^  the  w-riter  (see 
above),  the  dislocation  was  not  reduced  and  the  appliance  was  dis- 
carded at  the  end  of  a  year.  The  question  of  laminectomy  must  be 
given  serious  consideration.  Mixter^*  reports  an  interesting  experi- 
ence in  this  connection. 

Of  the  other  cervical  vertehrce,  uncomplicated  luxation  is  not  rare. 


Fig.    239. —  Appropriate    Fixation    Appliance    in    the    After    Treatment    of 
Fractures  of  the  Vertebrae  (Frazier). 

Luxations  between  the  fourth  and  fifth  and  the  fifth  and  sixth  verte- 
bra are  most  common.  They  are  classified  as  bilateral,  forward  and 
backward,  bilateral  in  opposite  directions,  and  unilateral  forward. 
The  bilateral  forward  and  the  unilateral  forward  are  the  usual,  the 
others,  the  exceptional,  luxations. 

The  bilateral  forward  luxation  is  caused  by  anterior  hyperflexion, 
though  posterior  hyperflexion  and  even  direct  violence  are  stated  to 
produce  the  condition.  All  of  Frazier 's'  eases  and  those  of  most 
observers  were  due  to  the  first  cause.  The  lesion  is  often  produced 
by  diving  into  shallow  water.  The  ligaments  and  the  intervertebral 
discs  are  extensively  torn ;  associated  fracture  of  the  spinous  processes 
and  laminae  is  common.     In  most  cases  the  spinal  cord  is  seriously 


682     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

injured.  In  bilateral  forward  dislocation,  the  head  is  usually  bent 
forward  and  the  spinous  process  of  the  vertebra  next  below  is  prom- 
inent; however,  in  not  a  few  instances,  the  head  is  bent  backward 
with  or  without  lateral  inclination.  In  the  upper  four  cervical  verte- 
brge,  a  prominence  may  be  felt  in  the  pharjnix.  Motion  in  the  spine 
is  absent  or  very  restricted.     The  head  is  fixed. 

The  prognosis,  because  of  injury  to  the  cord,  is  extremely  grave. 
Reposition  is  attainable  by  traction  and  slight  pressure  over  the  injury. 
It  may  be  necessary  to  reduce  first  one  side  and  then  the  other. 

In  unilateral  rotary  dislocation,  the  next  most  common  luxation  in 
the  cervical  region,  one  of  the  articular  surfaces  is  separated.  The 
causation  is  similar  to  that  of  other  luxations  in  this  situation,  and 
particularly  is  apt  to  be  found  in  a  twisting  motion  of  the  head.  The 
spinal  cord  frequently  escapes  injury.  The  condition  may  be  sus- 
pected if  the  head  is  held  in  a  position  not  unlike  that  of  torticollis. 
In  complete  luxations  the  transverse  process  of  the  dislocated  vertebra 
lies  in  front  of  the  transverse  process  of  the  vertebra  beneath ;  the  head 
is  inclined  to  one  side.  The  diagnosis  is  confirmed  by  the  deviation  of 
the  spinous  process  from  the  median  line,  by  palpation  of  the  deform- 
ity in  the  pharynx,  and  by  the  Rontgenogram. 

Reposition  is  accomplished  by  rotation  and  ahduction,  i.  e.,  the 
deformity  is  exaggerated,  the  articular  process  is  released  and,  by 
extension,  the  reduction  is  attained.  "Walton^^  regards  extension  as 
unnecessary  and  adds  that  elevation  of  the  head  and  rotation  accom- 
plishes the  purpose.  An  immobilizing  apparatus  should  be  worn  for 
at  least  two  months. 

In  hilateral  luxation  in  opposite  directions,  the  mechanism  is  that  of 
a  continuation  of  the  force  which  produces  a  unilateral  dislocation 
{rotation  and  ahduction),  so  that  the  opposite  articular  process  is  dis- 
placed backward.  The  condition  is  rare.  Frazier^  quotes  Malgaigne" 
as  reporting  the  first  case  of  this  sort.  The  diagnosis  is  made  possible 
onl}^  by  means  of  the  Rontgenogram.  Theoretically,  reposition 
should  be  made  by  rotation  and  ahduction,  first  one  side  and  then  the 
other.     Immohilization  should  be  maintained  for  three  months. 

Bilateral  hacJiward  luxations  are  also  very  rare.  They  are  produced 
by  sharp  flexion  of  the  neck  and  by  hackivard  pressure.  The  anterior 
inferior  edge  of  the  luxated  vertebra  engages  the  superior  surface  of 
the  underlying  vertebral  body;  as  the  causative  force  increases,  the 
capsular  ligaments  are  torn ;  the  intervertebral  disc  ruptures  and  the 
luxation  is  made.     Stanley^"  reports  a  case  in  which  the  injury  was 


SPECIAL  FRACTUKES  683 

produced  by  a  fall  backward  upon  the  head  and  back.  Quetsch^ 
reports  a  case  in  a  woman  who  fell  only  three  meters.  In  most  of 
the  recorded  cases,  the  head  is  tilted  backward,  the  face  upward,  and 
dysphagia  is  present. 

Frazier,"  whose  presentation  of  the  subject  is  particularly  lucid, 
suggests  that  many  cases  grouped  as  fractures  are  also  luxations ;  the 
cord  is  pinched  by  the  displaced  vertebras  and,  by  the  time  the  Ront- 
genogram  is  made,  only  an  inconsequential  fracture  is  revealed. 

Dislocations  of  the  Dorsal  Vertebrae. —  Luxations  of  dorsal  vertebraa 
are  not  common.  Blasius-^  has  collected  thirty-nine  cases,  twenty-two 
of  which  were  verified  by  autopsy. 

The  symptoms  are  not  distinctive.  The  diagnosis  is  made  by  the 
Rontgenogram.  Beposition  by  manipulation  is  possible;  however, 
the  open  method  (laminectomy,  Part  YIII)  gives  better  promise  in  this 
connection  ( Frazier^ ) . 

Lumbar  Luxations. —  Luxations  of  the  lumbar  vertebrae  (uncompli- 
cated by  fracture)  are  very  rare.  Borchardt--  reports  a  case.  The 
infrequency  is  attributable  to  the  anatomical  factors.  The  mechanism 
of  the  luxation  is  an  exaggeration  of  the  lumbar  lordosis  by  a  direct 
force  applied  from  the  front.  In  one  instance  the  luxation  was  pro- 
duced b}'  a  wagon  wheel  passing  over  the  body  (Borchardt--)  ;  in  two 
others,  it  was  caused  by  the  fall  of  a  lieav}'  object  upon  the  back,  the 
patient  lying  prone.  Schmid-^  reports  a  case  of  rotary  luxation  in 
the  lumbar  region.  In  all  of  the  cases  the  cauda  equina  was  injured. 
Frazier^  strongly  advises  the  open  treatment  (laminectomy,  p.  000) 
in  this  class  of  cases,  a  view  Avitli  which,  he  states,  Borchardt"-  agrees. 
The  rationale  of  this  is  based  on  the  assumption  that  farther  injury 
to  the  cord  is  obviated  in  this  way.  In  any  event,  the  anatomical 
conditions  do  not  seem  to  permit  of  the  successful  employment  of 
manipulation. 

As  to  the  treatment  of  luxations  of  the  vcrtchrce  in  general,  imme- 
diate reposition  is,  of  course,  very  desirable.  The  narcotic  state  is 
obligatory.  The  general  rule  as  regards  reposition  has  certain  reser- 
vations. There  is  no  doubt  that  cases  have  given  evidences  of  injury 
to  the  cord  ascribable  to  manipulation.  In  competent  hands,  laminec- 
tomy possesses  no  such  risks.  Frazier^  attaches  much  value  to  Bor- 
chardt's-^  acquiescence  with  this  view.  In  all  cases,  reposition  should 
be  followed  by  immobilization  for  several  months.  This  is  especially 
necessary  in  dislocations  of  the  cervical  vertebrae.  Frazier^  presents 
some  interesting  statistics  in  this  connection  which  are  too  voluminous 


684     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

to  be  included  here.     The  reader  is  referred  to  this  writer's  remark- 
able work  for  farther  elucidation. 

FRACTURE  DISLOCATIONS  OF  THE  VERTEBRA 

Fracture  dislocations  are  fractures  of  the  vertebrae  with  great  dis- 
placement {complete  fracture) .  They  are  usually  caused  by  the  appli- 
cation of  great  force,  though  they  may  be  the  result  of  muscular  effort. 
Gurlt^^  reports  a  case  of  this  sort. 

Indirect  violence  may  be  divided  into  overflexion,  overextension, 
extreme  lateral  deviation,  and  extreme  elongation. 

Overflexion  is  the  most  common  cause.  Usually,  a  heavy  weight  is 
brought  to  bear  upon  the  patient,  causing  extreme  flexion  of  the  head 
on  the  chest,  or  the  thoracic  upon  the  lumbar  vertebrae,  or,  perhaps,  of 
the  lower  lumbar  on  the  sacrum. 

The  cervical  vcrtchrcc  are  most  frequently  the  seat  of  fracture  dis- 
locations. A  great  force  applied  to  the  back  of  the  head  forces  the 
head  and  the  neck  into  extreme  flexion  and  a\ailses  one  or  both  of  the 
articular  processes  of  the  upper  vertebra.  Thus  the  force  of  the 
flexion  is  exerted  upon  the  intervertebral  disc,  which  tears,  and  the 
body  of  the  superior  vertebra  slips  forward,  usually  carrying  with  it 
more  or  less  of  the  anterior  portion  of  the  bod}'  of  the  vertebra  below. 

The  thoracic  vertebrge  are  less  susceptible  to  this  kind  of  injury 
than  are  the  cervical,  though  extreme  force  maj^  cause  it.  This  is  due 
to  the  more  vertical  position  of  the  articular  processes  and  the  fact 
that  the  anteroposterior  diameter  of  the  bodies  is  greater  than  the 
lateral. 

In  the  lumhar  vertehroe,  the  transverse  diameter  of  the  bodies  is 
greater  than  the  anteroposterior,  and  overflexion  is  a  frequent  cause 
of  fracture  dislocation.  The  leverage  in  this  situation  is  also  greater 
than  in  the  cervical  region. 

In  overextension,  the  luxation  is  usually  attended  with  fracture  of 
a  spinous  process,  though  this  is  not  always  the  case. 

In  the  cervical  spine,  extension  produces  the  quadrant  of  a  circle 
from  the  first  cervical  to  the  first  dorsal  vertebra ;  extension  beyond 
this  point  tends  more  to  fracture  of  a  spinous  process  or  one  of  the 
laminae  than  to  a  true  backward  displacement  of  a  vertebra.  When 
the  displacement  occurs,  the  posterior  tubercle  of  the  transverse 
process  of  the  superior  vertebra  glides  backward  and  over  the  articular 
process  of  the  inferior  vertebra,  which  practically  obliterates  the 
spinal  canal. 


SPECIAL  FRACTURES  685 

In  the  thoracic  spine,  the  long-,  slanting  spmous  processes  of  the 
upper  seven  vertebrae  interfere  with  extension.  In  the  lower  segment, 
that  part  of  the  posterior  aspect  of  the  body  of  the  superior  vertebra 
which  forms  the  anterior  margin  of  the  intervertebral  foramina  comes 
in  contact  with  the  superior  articular  process  of  the  vertebra  below 
and  forms  a  hindrance  to  backward  displacement.  In  order  to  have  a 
further  displacement,  it  is  necessary  that  the  superior  articular  process 
of  the  lower  vertebra  be  fractured.     This  is  usually  the  case. 

In  the  lumhar  spine,  when  the  bod}'  is  bent  backward  the  greatest 
amplitude  of  extension  involves  the  tenth,  the  eleventh,  and  the  twelfth 
dorsal  and  the  first  lumbar  vertebra.  In  this  region  a  greater  back- 
ward displacement  of  the  superior  vertebra  occurs  than  in  the  dorsal 
region.  Displacements  in  the  lumbar  spine  are  likel}'  to  be  extensive. 
They  are  usuall}'  attended  with  fracture  of  the  articular  processes. 

Direct  violence  or  impact  trauma  relates  to  the  application  of  direct 
violence  to  the  spine,  such  as  the  body  being  caught  between  the  floor 
and  a  moving  elevator. 

In  the  si/inptomatology  of  fracture  dislocations,  the  cord  as  well  as 
the  spine  must  be  considered.  As  far  as  the  former  is  concerned,  the 
symptoms  do  not  diifer  from  those  occurring  in  connection  with  other 
injuries  of  the  spinal  column  in  which  the  cord  is  involved.  The 
skeletal  injury  may  exist  without  lesion  of  either  the  cord  or  the 
nerve  roots.  There  may  or  may  not  be  any  discernible  deformity; 
even  in  severe  fracture  dislocations  a  replacement  may  obliterate  all 
external  evidences  of  the  injury.  In  all  cases  the  Rontgenogram  is 
of  great  assistance.  The  visible  deformity  is  in  the  nature  of  a 
kyphos,  although  lateral  displacement  may  also  manifest  itself  in  a 
discernible  deformity.  In  the  cervical  region,  the  deformity  is  likely 
to  be  rotary.  In  the  loiver  dorsal  and  upper  lumhar  reg'ions  comminu- 
tion of  the  vertebrae  is  attended  with  palpable  disturbance  of  the 
normal  alignment  of  the  spinous  processes.  Pain  is  severe  and  tender- 
ness is  acute.  The  treatment  of  this  class  does  not  differ  from  that 
already  discussed  in  connection  with  fractures  and  dislocations. 

FRACTURES  OF  THE  THORAX 

Fractures  of  the  Ribs. —  Fractures  (Fig.  240)  occur  with  greatest 
frequency  in  the  lower  (most  movable)  and  least  often  in  the  upper 
(best  protected)  ribs.  In  children,  the  ribs,  being  very  elastic,  are 
rarely  fractured. 


686    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  ribs  are  fractured  by  direct  and  by  indirect  violence.  Several 
ribs  may  be  simultaneously  fractured  when  the  thorax  is  compressed 
in  its  transverse  or  sagittal  diameter  (usually  at  the  axillary  angle). 

The  diagnosis  cannot  alwaj's  be  made  by  the  recognition  of  deform- 
ity. It  is  better  indicated  by  the  presence  of  crepitus  elicited  by  com- 
pressing the  thorax.  The  lung  is  often  punctured,  giving  rise  to 
hemoptysis.  Injury  to  the  lung  is  also  attended  with  hemothorax, 
pneumothorax,  and  with  traumatic  subcutaneous  emphysema  (p.  000). 


Fig.  240. —  A,  Fracture  of  the  Fifth,  Sixth,  and  Seventh  Eibs   (left  side). 
The  ribs  are  fractured  in  the  same  line    (the  axillary).     Union  with  more  or 
less  faulty  position  has  occurred  in  each. 

B,  Snows  A  Horizontal  Section  of  the  Sixth  Eib. 
Despite  the  faulty  position,  bony  union  is  clearly  manifest. 


The  latter,  at  times,  extends  over  the  greater  surface  of  the  body.  In 
mild  cases  it  is  restricted  to  the  axillary  region,  and  may  be  observed 
moving  with  inspiration  and  expiration ;  it  usually  soon  disappears. 

The  treatmc7it  consists  in  immobilizing  the  entire  thorax  by  means 
of  adhesive  plaster  (Fig.  241).  Excessive  bleeding  into  the  pleural 
sac  may  demand  aspiration.  "When  the  subcutaneous  emphysema 
threatens  strangulation,  it  is  justifiable  to  expose  the  puncture  in  the 
lung  and  close  it  by  suture.  In  rare  instances,  empyema  develops; 
this  calls  for  thoracotomy. 


SPECIAL  FRACTUKES  687 

Fractures  of  the  Costal  Cartilages. —  These  are  not  very  rare.  The 
lesion  occurs  at  the  point  of  junction  with  the  rib  or  in  the  cartilage 
itself  (Fig.  242).     The  illustration  shows  considerable  overriding  and 


Fig.    241. — •  Method   of   Immobilizing   Entire    Thorax 
WITH  Adhesive  Plaster  in  Fractured  Eibs. 

homj  union.  The  fracture  (which  occurs  late  in  life  when  the  elas- 
ticity of  the  cartilages  is  lessened)  is  usually  caused  by  direct  violence. 
The  fifth  to  the  eighth  cartilages,  being  most  exposed,  are  the  more 
frequently  fractured. 


688     INJURIES  TO  SOFT  PARTIS,  BONES  AND  JOINTS 

The  symptom&  are  similar  to  those  presented  by  fractured  ribs, 
except  that  soft  crepitus  is  obtained.  The  treatment  is  the  same  as 
that  of  fractured  ribs 

Fractures  of  the  Sternum. —  Fractures  of  the  sternum  (Fig.  242)  are 
produced  by  direct  and  by  indirect  violence;  the  latter  occur  in  con- 
nection with  overflexion  of  the  vertebral  column,  so  that  the  chin 


Fig    242.— a,   Fractured    Sternum.     B,   Horizontal   Section    of   a   Costal 
'cartilage:   faulty  position;  union  by  a  meager  bony  callus.     C,  Fracture 
Between  the  Manubrium  and  the  Body  of  the  Sternum;   healing  in  a 
faulty  position, 


SPECIAL  FRACTURES  689 

presses  upon  the  upper  edge  of  the  steruum.  In  this  way  the  sternum 
is  crushed  in  its  long  diameter  and  is  kinked.  The  fracture  may  also 
be  produced  in  hypcrextension  of  the  spinal  column  in  which  a  tearing 
fracture  occurs.     The  diagnosis  is  made  by  palpation. 

Reposition  is,  at  times,  difficult.  Helferich^*  places  the  body  of  the 
patient  on  a  wedge  shaped  pillow  and  appli-es  a  Glisson  sling  (Fig. 
236)  to  the  head.  When  there  is  no  deformity,  the  thorax  is  immobil- 
ized as  in  fractured  ribs  (Fig.  242). 

FRACTURES  OF  THE  UPPER  EXTREMITY 

Fractures  of  the  Clavicle. —  Fractures  of  the  clavicle  are  frequent 
(11  per  cent  of  all  fractures).  They  occur  in  all  portions  of  the  bone 
but  most  often  in  the  middle  third  (slightly  nearer  the  sternum). 
The  lesion  is  usually  due  to  indirect  violence  (fall  on  the  hand  with 
the  elbow  fixed,  or  on  the  shoulder)  ;  the  bone  is  bent  in  its  long 
diameter  and  suddenly  gives  wa}'.  As  the  collar  bone  comes  in  contact 
with  the  first  rib  when  the  shoulder  is  forcibly  pulled  downward,  it  is 
not  improbable  that  a  fracture  may  be  produced  in  this  way  when  an 
effort  is  made  to  lift  a  heavy  weight.  Children  often  have  infractions 
of  the  clavicle. 

The  symptoms  of  a  t^'pical  fracture  of  the  clavicle  are  character- 
istic. The  deformity  is  influenced  by  muscle  pull  and  b}'  the  weight 
of  the  shoulder.  The  sternomastoicl  displaces  the  sternal  fragment 
upward.  As  the  clavicle  is  concerned  in  holding  the  shoulder  upward, 
the  muscles  attached  to  the  thorax  and  the  arm,  and  the  weight  of  the 
latter  drag  the  outer  sector  of  the  hone  doivnward.  In  this  way,  the 
shoulder,  in  typical  cases,  is  caused  to  drop  helow  the  level  of  the 
opposite  one.  The  arm  lies  closer  to  the  thorax  and  the  axilla  on  the 
inner  side  is  narrowed.  In  addition  to  this,  the  arm  is  dropped  down- 
ward and  forward  and  is  rotated  inward  by  the  drag  of  the  pectoral 
muscles. 

Usually,  the  diagnosis  is  made  by  simple  inspection.  In  addition 
to  this,  the  ends  of  the  fragments  are  readily  palpahle.  In  cases  of 
infraction  and  in  fissured  fractures  deformity  may  be  absent.  In 
these  cases  the  Rontgenogram  is  a  necessary  aid  to  diagnosis. 

The  treatment  of  this  class  of  fracture  should  aim  at  exact  reposition 
and  this  must  be  maintained  by  an  apparatus  which  obviates  return 
of  the  deformity  during  repair.  The  time  when  more  or  less  ultimate 
malposition  was  regarded  as  inevitable  has  gone  into  history. 


690     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


For  the  purpose  of  reposition  an  assistant  stands  behind  the  patient 
and  makes  backward  and  upward  traction  upon  both  shoulders  (plac- 
ing a  knee  between  the  shoulders  if  necessary).  For  the  purpose  of 
maintaining  reposition,  the  Sayre  dressing  is  universally  employed. 
Three  strips  of  adhesive 
plaster  are  used,  of  which 
two  are  concerned  in 
overcoming'  the  deform- 
ity. The  first  strip  cor- 
rects the  inward  rotation 
of  the  arm ;  it  makes  trac- 
tion from  the  inner  side 
of  the  arm  outward,  and 
draws  the  shoulder  back- 
ward (Fig.  244). 

The  second  strip  lifts 
the  prolapsed  arm  by 
drawing  the  elbow  toward 
the  opposite  shoulder. 
The  third  strip  supports 
the  hand  and  crosses  the 
injured  shoulder,  thus 
making  moderate  pressure 
upon  the  fracture  from 
above  and  in  front.  The 
indication  not  met  by  the 
dressing  is  the  narrowing 
of  the  axillary  arch;  for 
this  purpose  a  pad  is 
placed  over  the  seat  of 
the  fracture  under  the 
third  strip. 

The  complications  con- 
sist in  injury  to  the 
hrachial  plexus  and  large 
blood  vessels.    These  may 

be  secondarily  involved  by  pressure  from  the  callus.  Injury  to  the 
dome  of  the  pleura  or  to  the  tip  of  the  lung  is  rare,  but  occasionally 
happens. 


Fig.  243. —  Fracture  of  the  Clavicle  with 
Typical  Displacement  op  the  Fragments. 

The  bone  is  fractured  at  the  junction  of  the 
sternal  and  middle  thirds.  The  sternal  frag- 
ment is  elevated  by  the  clavicular  portion  of 
the  sternomastoid  muscle.  The  shoulder  drops 
downward  and  forvsard. 


SPECIAL  FRACTURES 


691 


Fracture  of  the  clavicle  at  its  sternal  end  is  uncommon  and  is  not 
attended  with  much  displacement  of  the  frag-ments. 

Fracture  of  the  clavicle  at  its  acromial  end  is  attended  with  consid- 
erable malposition  of  the  fragments.  In  these  cases,  the  dressing  as 
described  must  be  especiallj'  carefulh'  applied. 

Fractures  of  the  Scapula. —  Fractures  of  the  scapula  are  rare  (about 
1  per  cent  of  all  fractures)  and  occur  in  various  forms.     Fractures  of 

the  hody  and  the  spine 
of  the  scapula  are  usu- 
ally produced  by  direct 
violence,  are  often  fis- 
sured, and,  as  a  rule,  are 
not  attended  with  much 
deformity.  Crepitus  and 
al)narmal  motility  are 
often  elicited,  especially 
when  the  arm  is  moved. 
The  treatment  consists 
in  immobilization  of  the 
arm  and  slight  pressure 
over  the  scapula. 

Fractures  of  the  neck 
of  the  scapula  are  un- 
common. As  a  rule,  the 
fracture  occurs  through 
the  surgical  neck,  i.  e., 
the  coracoid  process  re- 
mains associated  with 
the  fragment  connected 
to  the  shoulder  joint. 
The  lesion  must  be  differentiated  from  siihcoracoid  luxation  of  the 
humerus.  The  symptoms  consist  of  dropping  and  abduction  (slight) 
of  the  arm ;  the  acromion  is  prominent ;  elastic  fixation  is  absent ; 
elevation  of  the  arm  provokes  crepitus  and  abolishes  the  deformity, 
but  this  returns  as  soon  as  the  arm  is  released.  Occasionally  the  edge 
of  the  fracture  surface  may  be  felt  from  the  axilla.  The  dressing 
must  immobilize  the  scapula ;  the  dropping  of  the  arm  is  overcome 
by  the  use  of  an  axillary  pad  supported  by  a  Velpeau  bandage. 


Fig.  244. —  Satre  's  Adhesive  Plaster  Dress- 
ing FOR  Fracture  of  the  Clavicle. 


692     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Fracture  through  the  glenoid  cavity,  especially  at  its  inferior  aspect, 
is  rare.  It  is  attended  with  a  slight  dropping  of  the  arm,  and,  at 
times,  crepitus  may  be  elicited  by  holding  the  arm  in  a  horizontal 
position  and  moving  it  back  and  forth.  Occasionally,  the  coracoid 
process  is  avulsed  by  muscular  contraction.  The  acromion  is  frac- 
tured by  direct  violence.  The  diagnosis  is  easily  made  bv  palpation 
which  elicits  abnormal  motility  and 
crepitus.  The  treatment  consists 
in  immobilization  of  the  shoulder 
joint. 

Fractures  of  the  Humerus  (10  per 
cent  of  all  fractures.) — Fractures 
of  the  upper  end  of  the  humerus 
are  divided  into  those  of  the 
anatomical  neck,  those  in  the  region 
of  the  tubercles,  and  those  of  the 
surgical  neck. 

Fractures  of  the  upper  end  of 

the  humerus  are  caused  by  direct 

or  by  indirect  violence.     Indirect 

violence  may  break  the  bone  in  this 

situation  by  compressing  it  in  its 

long  diameter,  such  as  a  fall  upon 

the  elbow  which  forces  it  against 

the     acromion     process     or      the 

glenoid  cavit^'.     Direct  violence  is 

the  result  of  a  blow  or  a  fall  on 

the  outer  side  of  the  shoulder. 

Examination    of    these    fractures        ^>  Fracture  at  the  anatomical  neck; 
'  ,  .    ,,  ,  ,.  B,   fracture    throuoh    the    tubercles;    C, 

IS  not  eas}',  especially  when  there   fracture  at  the  surgical  neck, 
is  much  swelling.    Inspection  notes 

the  direction  of  the  shaft  of  the  humerus.  Palpation  is  of  great  aid. 
Normally,  the  tubercle,  the  intertubercular  sulcus,  and  the  region  of 
the  surgical  neck  are  readily  palpated ;  the  region  of  the  anatomical 
neck  and  the  articular  surface  of  the  head  of  the  bone  cannot  be  felt. 
Fracture  of  the  Anatomical  Neck. —  Fracture  of  the  anatomical 
neck  is  rare,  especially  in  the  uncomplicated  form.  If  the  fracture 
occurred  within  the  limits  of  the  articular  cartilage  the  fragment 
would  correspond  to  an  intra-articular  loose  cartilage,  such  as  is  often 


Fig.   245. —  Upper  End  of   Humerus; 
Lines  of  Possible  Fracture. 


SPECIAL  FRACTURES 


693 


found  in  the  knee  joint.  As  a  rule,  however,  the  fracture  is  not 
purely  intracapsular ;  the  fragment  may  be  held  in  place  by  a  portion 
of  the  capsule  and  may  be  vascularized  by  it,  and  the  line  of  the 


Pig.  246. —  Anatomical  Preparation-  of  a  Fractl'ee  of  the  Sltigical  Neck  of 

THE  Humerus. 

The  upper  end  of  the  lower  fragment  is  displaced  inward.  Its  proximity  to  the 
brachial  plexus  involves  great  danger  to  the  nerve  trunks.  The  biceps  tendon  i3 
incarcerated  between  the  fragments. 


solution  of  continuity'  may  run  through  the  bone  close  to  the  tubercle 
or  through  the  head  of  the  bone. 

Fractures  of  this  sort  are  caused  by  force  directed  against  the 

shoulder  or  by  compression  of  the  humerus  in  its  long  diameter.     The 


694     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

bone  may  be  impacted  between  the  tubercles  or  over  the  end  of  the 
shaft.  The  displacement  is  usually  slight ;  however,  in  some  instances, 
the  fragment  is  dislodged  from  the  glenoid  cavity  while  the  upper  end 
of  the  shaft  is  located  in  the  latter  portion. 

The  symptoms  are  those  of  a  severe  intra-articular  injury.  Under 
narcosis  it  is  possible  to  establish  the  fact  that  there  is  a  fracture 
above  the  tubercle.  Direct  palpation  of  the  fragment  is  not  possible ; 
however,  abnormal  mohility  and  crepitus  are  readily  made  out,  espe- 
cially when  the  arm  is  rotated.  Loss  of  function  is  complete  and 
pressing  of  the  bone  toward  the  glenoid  cavity  is  exceedingh'  painful. 


Fig.  247. —  Fractitre  of  the  Surgical  Neck  op  the  Humerus. 

The  ■VNTmkling  of  the  skin  at  the  inner  aspect  of  the  shoulder  is  due  to  the 
"impaling"  of  tlie  soft  parts  by  the  rough  end  of  the  shaft  fragment.  The  arm 
is  abducted  but  is  shortened. 


"When  the  upper  fragment  is  much  displaced,  operative  efforts  at  relief 
must  be  resorted  to  (p.  817). 

The  treatment  consists  in  fixation  of  the  arm,  including  axillary 
pad.  Early  passive  motion  is  indicated.  The  treatment  is  similar  to 
that  of  fracture  of  the  surgical  neck  (p.  696). 

Fracture  of  the  Surgical  Neck. —  Fracture  of  the  surgical  neck 
(of  the  humerus)  is  a  frequent  injury.  The  line  of  fracture  is  below 
the  tubercles  or  may  pass  through  them,  i.e.,  the  position  of  the  upper 
fragments  is  influenced  by  the  muscles  inserted  into  the  tubercles. 
The  lesion  is  usually  caused  by  direct  violence,  such  as  a  fall  upon  the 
shoulder,  though  it  occasionally  occurs  as  the  result  of  indirect  vio- 


SPECIAL  FKACTURES 


695 


lence,  as  a  fall  iipou  the  hand  or  elbow.     Impaction  also  not  infre- 
queutl}'  occurs.     Considerable  displacement  is  not  uncommon. 

For  the  purpose  of  understanding  the  condition  and  the  treatment, 
the  following  factors  must  be  taken  into  account :  The  upper  end  of 
the  dissociated  shaft  may  be  displaced  inward  or  outward.  "When  it 
is  displaced  inward,  the  arm  is  dbdwcted  (not  in  elastic  fixation)  and 


A  B 

Fig.  248. —  Impacted  Fkacture  op  the  Sltjgical  Keck  of  the  Humerus. 

A-A  show  the  normal  range  of  adduction  and  abduction.     B-B  show  the  re- 
striction of  motion  in  impacted  fracture. 

its  long  axis  merges  with  the  coracoid  process  or  with  the  clavicle. 
When  the  displacement  is  outward,  the  arm  is  adducted.  The  abducted 
position  and  displacement  of  the  shaft  of  the  bone  upon  the  thoracic 
wall  is  by  far  the  more  frequent  and  is  the  outcome  of  the  persistent 
force  applied  to  the  outer  aspect  of  the  shoulder. 

Symptoms. —  Palpation  of  the  side  contour  line  of  the  shoulder 
shows  that  the  dome  of  the  shoulder  beneath  the  acromion  process  is 


696     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

preserved;  the  arm  is  either  abducted  or  adducted  and  often  short- 
ened. Usually,  abnormal  mobility  and  crepitus  can  be  made  out.  At 
times,  it  is  possible  to  palpate  the  end  of  the  shaft  in  its  faulty  posi- 
tion, especially  when  it  is  located  beneath  the  major  pectoral  muscle 
or  has  penetrated  the  muscle  and  lies  beneath  the  skin.  In  the  latter 
instance,  a  condition  of  affairs  somewhat  resembling  those  occurring 
in  connection  with  subcoracoid  dislocation  is  presented ;  however,  the 
shortening  and  the  other  symptoms  mentioned  should  make  the  differ^ 
entiation  easy.  Impaction  always  presents  diiSculties  as  regards  the 
diagnosis;  however,  exclusion  of  dislocation  should  be  possible. 

Treatment. —  Narcosis  should  be  emploj'ed  for  reposition.  When 
impaction  is  present  no  effort  at  reduction  should  be  made.  Fixation 
of  the  entire  arm,  the  shoulder,  and  the  neck  is.  essential  and  suffices 
when  there  is  no  tendency  to  return  of  the  malposition.  "When  the 
deformity  tends  to  recur,  amhulatory  apparatus  must  he  discarded, 
and  rest  in  bed  and  permanent  extension  is  indicated. 

The  methods  of  treatment  of.  fractures  of  the  humerus,  loith  the  exception 
of  those  near  the  elboiv  joint,  may  be  taken  up  together. 

Fia^ation  of  the  fracture  is  attained  by  the  use  of  splints,  molded 
gypsum  splints,  by  closed  gypsum  appliances,  and  b}-  extension  appa- 


FiG.  249. —  A,  Fracture  of  the  Surgical  Neck  of  the  Humerus  with  Inward 
Luxation  of  the  Shaft;  the  arm  is  abducted.  B,  Fracture  op  the 
Surgical  Neck  of  the  Humerus  with  Outward  Luxation  of  the  Shaft: 
the  arm  is  adducted. 


SPECIAL  FRACTURES 


697 


ratus.  In  fixatiuu  the  following  is  to  be  taken  into  account:  (1) 
Immobilization  of  the  region  of  the  fracture,  the  elbow,  the  forearm 
and  the  neck  being  fixed.  (2)  Correct  position  of  the  arm  at  the 
shoulder  and  elbow  joints;  abduction  of  the  shoulder;  flexion  at  the 
elbow.  (3)  Not  too  prolonged  immohilization,  as  passive  motion  is  of 
great  importance;  closed  circular  gypsum  dressing  should  be  cut 
down  and  arranged  so  that  this  is  possible,  and  then  be  reapplied.     In 

this  connection,  the 
so-called  collar  splint 
of  Albers-'  (Fig. 
250)  is  of  great 
value.  This  covers 
the  neck  to  the  hair 
line  and  extends  over 
the  posterior  aspect 
the  arm,  over  the 
flexed  elbow,  and 
over  the  supinated 
forearm  to  the  back 
of  the  hand.  After 
the  soft  gypsum  is 
molded  to  the  parts, 
it  is  held  in  place 
with  a  roller  band- 
age. "Wlien  it  is  nec- 
essary to  hold  the 
arm  in  abduction,  the 
closed  gypsum  dress- 
ing of  Glassner-® 
(Fig.  251)  is  of  serv- 
ice. The  thorax  and 
arm,  including  the 
elbow  (flexed  at  a  right  angle)  and  forearm  to  the  wrist,  are  encased 
as  shown  in  Fig.  251.  At  the  end  of  the  second  week  the  dressing  is 
opened  by  means  of  a  gutter  cut  into  the  thoracic  portion  of  the  splint, 
which  communicates  with  another  cut  into  the  inferior  aspect  of  the 
arm,  and  a  sector  is  cut  from  the  outer  side  of  its  arm  portion.  Thus 
the  apparatus  is  easil}^  removed,  the  arm  subjected  to  passive  motion 
and  massage,  and  the  dressing,  which  now  consists  of  two  removable 
splints,  is  reapplied  at  frequent  (daily)  intervals. 


Fig.  250. —  Collar  Gypsum   Splint. 


698     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  simplicity  of  the  apparatus  shown  in  Fig,  252,  which  originated 
with  Middledolp,^'  has  a  certain  appeal.  Its  mode  of  application  is 
evident  from  the  picture,  which  does  not,  however,  show  the  padding. 
The  forearm  and  elbow  should  be  immobilized  separately. 

In  cases  of  fracture  of  the  upper  end  of  the  humerus,  and  in  some 
involving  the  shaft  of  the  bone,  when  the  malposition  exhibits  a  tend- 
ency to  recur  it  is  best  to  put  the  patient  to  bed  and  use  suspension  and 
traction.  By  this  means  the  deformity  is  overcome  and  the  seat  of 
the  injury  is  accessible  to  massage  almost  at  once  without  disturbing 
the  relationship  of  the  bony  fragments.    For  the  purpose  the  measures 


Fig.    251. —  Closed  Gypsum    Dressing    for   Feactuke   of 
THE  Upper  Humerus. 


employed  in  connection  with  the  modified  Balkan  frame  (p.  657)  are 
exceedingly  satisfactory.  The  method  of  arrangmg  the  adhesive  straps 
is  shown  in  Fig.  253.  It  wall  be  seen  that  the  strips  are  attached  to 
pieces  of  webbing  w^hich  in  turn  are  attached  to  a  spreader  made  of 
thin  board  0.125  meter  (5  in.)  long  and  0.10  meter  (4  in.)  wide,  to  the 
center  of  which  a  cord  is  fixed.  To  the  ends  of  this  spreader  are  at- 
tached bands  of  elastic  webbing,  0.02  meter  (%  in.)  wide;  these  sup- 
port a  round  bar  of  wood  at  a  height  which  puts  it  just  wuthin  reach 
of  the  fingers  so  that  the  patient  can  pull  it  down  into  the  grasp  of 
the  hand  and  thus  exercise  the  fingers —  an  arrangement  which  is  of 
special  value  in  cases  of  nerve  injury. 


SPECIAL  FRACTURES 


699 


Traction  to  the  lower  fragment  of  the  humerus  is  most  efficiently 
made  by  means  of  adhesive  straps  as  shown  in  Fig.  253. 

If  no  direct  suspension  of  the  arm  is  made  the  fragments  tend  to 
bow  backward.  To  prevent  this  a  board  sling,  nearly  equal  in  width 
to  the  length  of  the  humerus,  is  placed  under  the  arm  (Fig.  253) 
w^hieh  is  then  suspended  as  shown  in  Fig.  25-4. 


Fig.   252. —  Triangular  Splint   INfADE   op   Tin    (padding 
omitted  for  the  sake  of  clearness). 


Blake^^  uses  the  modified  Balkan  frame  in  almost  all  fractures  of 
the  humerus  including  those  entering  the  shoulder  and  elbow  joints. 
The  modifications  of  apparatus  necessary  to  overcome  the  regional 
difficulties  are  not  difficult  to  meet.  He  says :  "As  most  cases  require 
abduction  of  the  arm,  the  forearm  and  arm  are  suspended  in  different 
planes  in  relation  to  the  longitudinal  axis  of  the  bed,  so  that  two  longi- 
tudinal bars  must  be  used,  the  forearm  being  suspended  to  the  outer. 


700    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  distance  between  the  suspending  bars  is  regulated  to  conform  with 
the  desired  abduction  and  the  outward  rotation  of  the  lower  fragment. 
*' Traction  must  always  be  made  in  the  axis  of  the  upper  fragment. 
The  position  of  the  latter  depends  upon  the  site  of  the  fracture  and 
the  preservation  of  the  attachments  of  the  muscles,  and  varies  greatly. 
Its  exact  situation  can  only  be  determined  by  means  of  X-ray;  the 
apparatus  for  treatment  should  be  adjusted  until  the  lower  fragment 
is  in  line  with  the  upper  fragment.  Generally  speaking,  the  higher 
the  fracture  the  greater  the  abduction  and  outward  rotation  of  the 
upper  fragment.     In  rare  cases  the  pectoral  may  adduct  the  upper 


Fig.  253. —  The  Principle  of  Suspension  and  Traction 
FOR  Fractures  op  the  Humerus  (Blake). 


fragment,  and  the  deltoid  draw  the  lower  fragment  upward  on  its 
outer  aspect. 

"In  the  lower  fractures  traction  may  usually  be  made  in  the  axis  of 
the  bed  and  the  traction  pulley  attached  to  a  cross  bar  on  the  frame 
at  the  foot  of  the  bed.  In  fractures  of  the  surgical  neck,  in  which 
the  fractured  surface  of  the  upper  fragment  may  look  almost  directly 
upward,  the  arrangement  illustrated  in  Fig.  254  has  been  found 
efficient  and  surprisingly  comfortable. 

"The  weight  necessary  for  traction  varies  with  the  musculature 
of  the  arm.     It  is  generally  from  1,500  to  2,000  grammes. 


SPECIAL  FRACTURES 


701 


"The  weight  attached  to  the  sling  should  just  balance  that  of  the 
arm  proper,  while  the  amount  attached  to  the  forearm  should  corres- 
pond to  the  weight  of  the  latter.  About  1,500  grammes  are  necessary 
for  each  (i.  e.,  arm  and  forearm)." 

Transtubercular  Fracture. — Transtubercular  fracture,  i.  e.,  a 
transverse  fracture  on  a  level  with  the  tubercles,  is  usually  caused  by 


Fig.  254. —  Position  of  Extreme  Abduction  and  External 
KoTATiON  Necessary  in  the  Treatment  of  Some  Frac- 
tures OF  THE  Upper  End  of  the  Humerus  (Blake). 


a  blow  or  a  fall  upon  the  outer  side  of  the  shoulder.  The  malposition 
is  similar  to  that  obtaining  in  fracture  of  the  surgical  neck  of  the 
humerus;  impaction  may  occur.  The  treatment  is  the  same  as  for 
fracture  of  the  surgical  neck. 

Traumatic  Epiphyseal  Separation. — Traumatic  separation  of  the 
epipM'sis  at  the  upper  end  of  the  humerus,  because  of  its  relative 
frequency,  is  of  great  surgical  importance.    It  occurs  before  ossifica- 


702     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


tion  of  the  intermediary  cartilage   (metapliysis)   takes  place  and  is 
caused  by  a  fall  on  the  shoulder  or  the  arm. 

The  clinical  picture  is  often  very  characteristic  and  is  similar  to 
that  presented  by  a  fracture  of  the  surgical  neck  of  the  humerus.  The 
dome  of  the  shoulder  is  preserved  by  the  head  of  the  bone.  Under 
narcosis  it  is,  at  times,  possible  to  elicit  a  false  point  of  motion  and  soft 
crepitus.  The  displacement  may  be  considerable  in  extent;  the  upper 
end  of  the  diaphj^sis  is  luxated  inward  and  forward,  and  may  occa- 
sionally be  seen  as  a  sharp  cornered  prominence,  especially  when 
viewed  from  above.  Reposition  is  likel}^  to  be  difficult  even  under 
narcosis ;  when  it  succeeds,  the  treatment  is  the  same  as  in  fracture  of 
the  surgical  neck.  If  repo- 
sition by  manipulation  fails, 
the  open  method  is  indicated. 
Fixation  is  best  accom- 
plished by  means  of  a  steel 
nail. 

Exact  apposition  of  the 
separated  parts  is  necessary 
in  order  to  obviate  a  lifelong 
deformity  and  impairment 
of  function.  To  this  may  be 
added  that  incomplete  repo- 
sition after  a  lesion  of  the 
epiphyseal  cartilage  is  fol- 
lowed by  disturbances  of 
growth,  the  humerus  re- 
maining shorter  than  the 
uninjured  one.  It  is  often 
necessary  to  employ  the  extension  and  counterextension  treatment. 

In  the  newly  dorn,  epiphyseal  separation  of  the  upper  end  of  the 
humerus  occurs  during  delivery.  In  these  cases,  the  epiphysis  is 
likely  to  be  rotated  outward.  When  the  lower  fragment  heals  in 
this  faulty  position,  serious  impairment  of  function  results. 

Isolated  Fracture  of  the  Major  and  Minor  Tubercles. —  These 
(avulsion  fractures)  often  occur  in  connection  with  subcoracoid  dis- 
location of  the  humerus.  The  minor  tubercle  is  rarely  fractured.  The 
condition  may  be  suspected  in  the  presence  of  crepitus,  localized 
tenderness,  and  a  false  point  of  motion.  The  Rontgenogram  makes 
the  diagnosis.    The  treatment  is  directed  toward  relaxation  (by  pos- 


flg.   255. eontgenogram   of    traumatic 

Epiphyseal   Separation   at   Upper   End 
OF  Humerus    (Stewart). 


SPECIAL  FRACTURES 


703 


ture)  of  the  muscles  attached  to  the  avulsed  tubercle,  and  immobili- 
zation of  the  arm,  as  in  fracture  of  the  surgical  neck.  When  a  fracture 
of  this  sort  occurs  in  connection  with  a  preglenoid  dislocation,  the 
latter  must  be  reduced  by  traction  and  direct  pressure,  not  by  the 
rotation  method. 


Fig.  256. —  A,  Anatomical  Preparation  Showing  Location  of  Musculospiral 
Nerve    with    Eegard    to    Fracture    of    the    Shaft    of    the    Humerus. 

B,    SUPRACONDYLOID    FRACTURE  EeADILY   MISTAKEN   FOR   POSTERIOR   LUXATION 

AT  THE  Elbow  Joint. 

Fractures  of  the  Diaphysis  of  the  Humerus  (Fig.  256). —  Frac- 
tures through  the  shaft  of  the  humerus  are  caused  by  direct  or  indirect 
violence.  As  a  rule,  the  diagnosis  presents  no  ditBeulties ;  abnormal 
mobility,  crepitus  and  the  malposition  are  readily  recognized.  Wlien 
the  fracture  is  located  below  the  insertion  of  the  deltoid  muscle,  the 


704     INJUKIES  TO  SOFT  PAKTS,  BONES  AND  JOINTS 


latter  is  likely  to  displace  the  upper  fragment  outward.  In  fractures 
of  the  middle  of  the  shaft,  the  radial  nerve  may  be  primarily  injured 
or  secondarily  involved  by  pressure  of  the  callus,  in  which  it  often 
lies  in  a  deep  gutter.  The  presence 
(or  absence)  of  this  primary  injury 
should  be  determined  before  the  part 
is  immobilized.  Involvement  of  the 
nerve  is  shown  by  paralysis  of  the 
extensors  of  the  hand  audi  character- 
istic sensory  paralysis.  "When  the 
paralysis  appears  late,  the  surgeon  is, 
at  times,  unjustly  accused  of  faulty 
teclmic  in  the  application  of  the 
dressing. 

Union  after  proper  treatment  is 
likely  to  be  uncomplicated;  however, 
the  occurrence  of  pseudo~arthrosis  in 
this  situation  is  relatively  frequent. 
This  is  due  to  the  difficulties  encoun- 
tered in  the  immobilization  of  the 
fragments ;  and  because  of  their  con- 
siderable malposition  and  the  likeli- 
hood of  interposition  of  soft  parts  in 
fractures  of  this  class. 

Treatment. — In  applying  the  circu- 
lar closed  dressing  with  inclusion  of 
the  shoulder  and  elbow  joints  (Fig. 
251),  the  axilla  must  be  preserved 
from  undue  pressure.  The  triangular 
splint  (Fig.  252)  or  the  gypsum  dress- 
ing, as  sho-\\ai  in  Fig.  250,  may  be 
used.  In  cases  in  which  the  malpo- 
sition shows  a  tendency  to  recur,  ex- 
tension and  count erextension  (Figs. 
253  and  254)  must  be  employed. 

Fractures  at  the  Lower  Exd  of 
THE  Humerus. —  Under  this  head  are  included  the  fractures  up  to  the 
origin  of  the  supinator  longus  muscle.  The  modern  terminology 
applied  to  the  various  portions  of  the  lower  end  of  the  humerus  is 
represented  in  Fig.  258. 


Fig.  237. —  Eoxtgexogra^vi  of 
Torsion  Fracture  op  the 
Humerus. 

The  injury  is  very  likely  to  be 
attended  with  involvement  of  the 
radial  nerve. 


SPECIAL  FRACTURES 


705 


The  diagnosis  of  fractures  in  this  situation  is  often  difficult  and 
demands  careful  inspection  and  palpation. 

The  topography  of  the  relationship  that  the  bou}'  prominences 
bear  to  one  another  is  very  important,  especially  that  of  the  epicondyles 
to  the  olecranon  with  the  forearm  extended  (Fig.  259)  and  flexed 
(Fig.  260).  The  injured  side  must  alwaj^s  be  compared  to  the  sound 
limb  in  this  connection.  In  these  cases,  the  Rontgenographic  exami- 
nation is  not  as  valu- 
ably .as  has  been 
generally  believed. 
In  all  cases  limbs 
should  be  photo- 
graphed in  the  same 
positions. 

Fractures  in  this 
location  cannot  be 
arranged  in  definite 
classes,  as  the  solu- 
tion of  continuity 
of  the  bone  often 
presents  individual 
peculiarities.  The 
lines  of  the  fracture 
shown  in  Fig.  261 
must  be  taken  into 
account  in  the  dif- 
FiG.  258.- The  Modern  Terminology  Applied  to  the  ferential  diagnosis, 
Anatomy  of  the  Lower  End  op  the  Humerus  (left) .    .  .  o  > 

m  all  instances. 
A,  Coronoid   fossa;    B,   median  epieondyle;    C,   radial         Qttdi?  */-.rvxTT-i 
fossa;    D,    lateral    epieondyle;    E,    trochlea    humeri;    F,         oufkacon  D\LOI  D 
capitulum  humeri.  FRACTURES    ( Fig. 

256)  are  usually 
caused  by  a  fall  upon  the  elbow  and  hand  and  are  ver}^  frequent  in 
children.  A  flexed  motion  of  the  shaft  of  the  humerus  dislocates  the 
lower  fragment  forward,  or  it  may  be  dislocated  backward  hy  hyper- 
extension;  the  latter  is  by  far  the  more  frequent.  The  extension 
fracture  is  etiologically  similar  to  posterior  dislocation  of  the  elbow 
(Figs.  262-263). 

Symptoms. — The  malposition  is,  as  a  rule,  typical.    This  is  especially 
true  of  transverse  supracondyloid  and  ollique  fractures  which  belong 


706     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

to  the  extension  class.  The  deformity  is  like  that  of  a  posterior  lux- 
ation of  the  forearm;  the  drag  of  the  triceps  muscle  displaces  the 
fragment  backward.     In  the  rare  flexion  fractures,  the  oblique  course 


Fig.    259. —  A    Line    Drawk 

BETWEEN    THE   TWO   EpICON- 

DYLEs  Crosses  the  Tip  of 
THE  Olecranon  when  the 
Forearm  is  Fully  Ex- 
tended. 


Fig.  260. —  Triangle  Formed  by  Lines 
Drawn  from  the  Epicondyles  to  the 
TIP  OF  the  Olecranon  with  the  Fore- 
arm Flexed. 


Fig.  261. —  The  Various  Forms  of  Fracture  at  the  Lower  End  of  the 

Humerus. 

a,   Isolated   fracture   of  the   internal   epicondyle;    T),   oblique    fracture   of  the 

external  condyle ;  c,  intra-articular  avulsion  of  the  capitulum  humeri ;  d,  transverse 

supracondyloid  fracture;  e,  oblique  fracture  of  the  medial  condyle;  /,  transverse 

fracture  of  the  articular  process;  g,  isolated  fracture  of  the  external  epicondyle. 


SPECIAL  FRACTURES 


707 


of  the  fracture  does  not  permit  of  a  posterior  displacement.  The 
pointed  end  of  the  diaphysis  is  luxated  backward  and  may  impale 
the  triceps  muscle,  while  in  exetnsion  fracturers  it  impinges  upon  the 
brachialis  anticus. 

In  the  examination,  the  lower  end  of  the  humerus  is  grasped  at  its 
epicondyles  and  the  direction  in  which  the  fragment  may  be  dis- 
placed is  tested.  It  is  also  possible  to  produce  the  displacement  by 
forcing  the  flexed  forearm  toward  the  fixed  upper  arm ;  this  maneuver 


Fig.  262. —  Diagram  of 
Extension  Fracture, 

Line  of  fracture  runs 
do^\Tiward  and  forward 
from  behind  and  above 
(very  frequent). 


Fig.  263. —  Diagram  of  Flexion 
Fractxtre. 

Line    of    fracture    runs    down- 
ward  and    forward    (very   rare). 


produces  crepitus.  The  forearm  may  also  be  abducted  and  adducted 
to  a  slight  extent.  The  relationship  of  the  olecranon  to  the  epicon- 
dj'les  is  normal;  at  times,  palpation  reveals  the  position  of  the  frag- 
ments. Reposition  is  accomplished  by  extension  but  recurs  when  the 
traction  is  released. 

Reposition  should  be  performed  under  narcosis.  Unnecessary  vio- 
lence results  in  overcorrection,  and  the  fragment  lodges  in  the  re- 
verse position.  Fij-ation  is  achieved  by  means  of  splints,  the  elbow 
being  flexed  or  extended  according  to  which  of  these  overcomes  the 


708     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

displacement  and  retains  it  in  the  corrected  position.  In  the  adult, 
it  is  not  infrequently  necessary  to  use  permanent  weight  and  pulley 
extension;  the  arm  is  extended  upon  a  sliding  board  with  the  hand 
held  in  supination.  The  dressing  shown  in  Fig.  265  often  accom- 
plishes the  purpose.  Fractures  of  this  sort  in  children  demand  es- 
pecial care.  Removal  of  the  dressing  and  verification  of  the  position 
of  the  fragments  under  narcosis  once  a  week  is.  worth  while.  Fre- 
quent control  by  means  of  Rontgenogram  examination  is  also  advis- 


FiG.   264.—  Various   Fractures  in   Region   of  Elbow  Joint. 

A,  Transverse  fracture  and  partial  epiphyseal  separation;  B, 
longitudinal  fracture  of  upper  end  of  ulna;  separation  of  olecranon; 
C,  longitudinal  fracture  of  humerus  extending  into  elbow  joint; 
-D,  intra-articular  fracture  of  the  capitulum  and  the  external  epi- 
condyle;  E,  T  fracture  of  lower  end  of  humerus. 

able.  Immobilization  must  not  be  long  continued.  Despite  the  great- 
est care,  healing  with  deformity  and  permanent  loss  of  function  can- 
not always  be  avoided. 

Complicating  injury  to  the  nerves  (the  ulnar,  median,  and  radial) 
is  not  uncommon.  Occasionally,  the  cuhital  vessels  are  torn ;  this 
involves  great  danger  of  gayigrene. 

In  transverse  fracture  of  the  true  articular  process  (Fig.  261),  the 
separation  occurs  below  the  epicondyles  on  a  line  with  the  edge  of  the 
articular  cartilage,  i.  e.,  an  intra-articular  injury,  although  the  frac- 


SPECIAL  FRACTURES 


709 


ture  may  extend  outside  the  joint.  The  injury  is  rare  and  is  caused 
by  a  fall  on  the  elbow  or  the  hand.  Experimentally,  it  may  be  pro- 
duced by  compression  of  the  humerus  in  its  long  axis. 

To  this  class  of  injury  belongs  the  traumatic  separation  of  the  lower 
epiphysis  of  the  humerus  (Fig.  264,  A)  which  occurs  in  children  and 
young  persons. 

The  symptoms  are  those  of  a  contusion  of  the  joint.  The  malposi- 
tion is  slight.     Passive  motion  is  only  partially  restricted  and  not 


Fig.  265. —  Molded  Splints  Fitted  to  the  Position  op 
THE  Elbow  Joint  for  Fracture  op  the  Lower  End 
OP  THE  IIujierus. 


painful ;  however,  forcing  of  the  forearm  against  the  joint  surface 
of  the  humerus  is  painful.  When  the  epicondjdes  are  fixed,  a  moderate 
degree  of  false  motion  may  be  elicited  by  manipulating  the  forearm 
in  various  directions ;  this  is  also  attended  with  crepitus. 

Reposition  is  not  difficult.  Fixation  in  flexion  or  extension.  Early 
passive  motion. 

Oblique  fractures  of  the  lower  end  of  the  humerus  involve  either 
the  outer  or  the  inner  region  of  the  joint.     In  rare  instances,  both 


710    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


sides  are  fractured  (double  oblique  fracture  or  condyloid  fracture). 

Fractures  of  this  sort  are  common  and  are  attended  with  consider- 
able displacement  of  the  relationship  of  the  elbow  joint.  Careful 
palpation  of  the  bony  prominences  and  testing  of  abnormal  mobility 
leads  to  a  tentative  diagnosis.  The  manipulations  are  not  satisfactory 
unless  carried  out  under  narcosis;  in  this  way  the  fragments  may 
often  be  recognized.  A 
knowledge  of  the  nor- 
mal form  of  the  bone 
and  a  comparison  of 
the  two  sides  should 
make  recognition  of 
the  condition  possible. 
Efforts  at  lateral  mo- 
tion in  the  elbow  joint 
(abduction  and  adduc- 
tion), in  the  extended 
position  with  the  hand 
supinated,  reveal  which 
is  the  injured  side. 
Motion  is  only  possible 
toward  the  uninjured 
side;  that  toward  the 
injured  side  is  pre- 
vented by  the  untorn 
lateral  ligament,  when 
the  articular  body  is 
not  entirely  separated 
and  is,  in  part,  held  in 
place. 

Oblique  fracture  of 
the    external    condyle 

(Fig.  264)  is  by  far  the  more  frequent.  It  is  caused  by  direct  force 
applied  to  the  outer  side  of  the  joint,  or  by  indirect  violence  through 
the  radius  (fall  on  the  hand),  or  by  continuation  of  force  applied  to 
the  olecranon  (fall  on  the  inner  side  of  the  elbow).  In  a  way,  frac- 
ture of  the  outer  condyle  is  analogous  to  outward  and  backward  lux- 
ation of  the  forearm. 

Symptoms. — Abnormal  adduction  of  the  extended  forearm ;  normal 


Fig.  266.^ —  Rontgenogram  of  Supracondyloid 
Fracture  of  Humerus  (Harlem  Hospital 
case). 


SPECIAL  FRACTUKES 


711 


abduction  in  extension  may  be  absent.  Pressure  with  the  forearm  in 
abduction  causes  severe  pain.  The  fractured  condyle  can  be  moved 
upon  the  rest  of  the  humerus,  eliciting  crepitus.  The  broken  frag- 
ment is  often  displaced  upward  (by  pressure  of  the  radius  caused 
by  traction  of  the  biceps  and  musculature  of  the  forearm),  giving 
a  valgus  position  to  the  forearm,  and  is  rotated  forward. 

The  prognosis  in  fractures  of 
this  sort  is  not  good,  as  moderate 
maintenance  of  the  malposition 
restricts  the  mobility  of  the  joint. 
In  children,  time  and  protracted, 
patient  employment  of  passive 
motion,  such  as  the  Zander  appa- 
ratus, do  much  to  reestablish  the 
utility  of  the  joint.  Despite  this, 
a  certain  degree  of  loss  of  func- 
tion and  some  valgus  deformity 
always  remain. 

The  treatment  consists  in  repo- 
sition by  flexion  of  the  pronated 
elbow,  under  narcosis.  Immobili- 
zation in  flexion,  for  a  time,  then 
extension  and  fixation  in  the  lat- 
ter position.  This  is  to  be  repeated 
several  times.  For  the  purpose, 
moldable  tin  splints  (Fig.  265), 
which  may  be  bent  to  meet  the 
varying  positions,  are  of  great 
value.  In  some  instances,  per- 
manent extension  may  be  neces- 
sary (see  Balkan  frame  p.  658). 
Oblique  fracture  of  the  infernal 
condyle  is  uncommon.  It  is  caused 
by  pressure  against  the  median  area  of  the  articular  end  of  the 
humerus  (fall  on  the  elbow). 

Sym.ptoms. — Severe  pain  on  pressure.  The  fragment  is  luxated 
upward.  Crepitus  is  present.  Abnormal  abduction  with  the  forearm 
extended  is  possible.  The  fragment  may  be  displaced  upward  by 
manipulation. 


Fig.  267.— Frontal  View  op  Fig.  266. 


712     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


The  prognosis,  because  of  the  slight  degree  of  luxation,  is  good. 

Reposition  hy  traction  with  the  forearm  flexed.  Fixation  as  for 
fracture  of  the  external  condyle. 

Fractures  of  the  epicondyles  maj-  be  single  or  may  occur  in  con- 
nection with  luxations  of  the  elbow  joint.  The  diagnosis  is  based  on 
the  displacement  of  the  fragment,  which  is  easily'  palpated.  In  addi- 
tion to  this,  it  may  be  noted  that  moderate  flexion  and  extension  of  the 
elbow  joint  are  painless,  while  free  motions  of  this  nature  (stretching 
of  the  lateral  ligaments)  are  painful. 

Fracture  of  the  internal  epicondyle   (Fig.  268)  is  frequent.     It  is 
rarely  caused  by  direct  violence,  but  is 
often  avulsed  by  the  internal  lateral 
ligament  in  luxation  of  the  forearm. 

Symptoms. —  The  moveable  epicon- 
dyle is  readily  palpable.  It  may  be 
displaced  downward  to  below  the  level 
of  the  trochlea.  The  forearm  ma}-  be 
passively  abducted  to  an  abnormal 
extent. 

Reposition  is  difficult.  It  ma^^  be 
necessary  to  fix  the  fragment  by  ope- 
rative means,  such  as  nailing,  suture, 
etc.  In  old  cases,  resection  of  the 
avulsed  epicondyle  is  indicated. 

Fracture  of  the  external  epicondyle 
is  also  very  rare;  it  occurs  in  connec- 
tion with  luxations  of  the  forearm.  The 
diagnosis  and  treatment  are  similar  to 
those  stated  in  connection  with  fracture  of  the  internal  epicondyle. 

Intra-articular  fracture  of  the  capitulum  humeri  occurs  in 
two  types  (Lorenz^'')  ;  complete,  and  incomplete. 

The  incomplete  fracture  consists  in  a  decortication  of  the  cartilag- 
inous coating  of  the  bone  and  occurs  in  young  persons.  It  is  caused 
by  indirect  violence,  such  as  a  fall  upon  the  hand,  and  is  attended 
with  considerable  deformity  and  some  swelling  of  the  joint.  Ex- 
tension of  the  forearm  is  hindered;  the  other  motions  are  not  markedly 
impaired.  The  limitation  of  extension  is  due  to  incarceration  of  the 
loose  cartilage.  As  a  rule,  the  latter  is  displaced  backward  and  may 
be  palpated  in  this  location. 


Fig.  268. —  Rontoenogram  of 
AN  Avulsion  Fracture  of 
THE  Internal  Epicondyle 
(Harlem  Hospital  case). 


SPECIAL  FKACTURES 


713 


The  complete  fracture  is  characterized  by  separation  of  the  entire 
articular  process,  and  is  caused  by  a  fall  upon  the  flexed  elbow  (direct 
violence).  The  fragment  is  displaced  forward  into  the  hollow  of  the 
elbow,  where  it  is  likely  to  become  adherent.     At  times,  the  frag- 


FlG. 


269. EOXTGENOGRAM     OP     FrACTUKE     OF     BoTH     BoXES 

OF    THE    FOREARir. 


A,  The  deformity  is  great.  The  upper  end  of  the  lower 
fragment  of  the  radius  is  concealed  by  the  shadow  of  the 
slightly  displaced  ulnar  fracture,  showing  the  necessity  for 
taking  pictures  in  both  directions;  B,  the  same  case  after 
reposition  by  the  open  method;  wiring  of  radius  (Helferich). 


ment  is  completel}'  rotated  and  the  ligaments  and  other  portions  of 
the  joint  are  severeh'  injured. 

Both  these  injuries  are  intra-articular.  The  avnlsed  fragment  may 
be  regarded  as  a  corpus  mohile.  Resection  of  the  fragment,  through 
a  lateral  incision,  is  indicated. 


714    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Fractures  of  the  Forearm  (22  per  cent  of  all  fractures). — Frac- 
tures of  the  forearm  may  consist  of  both  bones,  or  of  the  ulna,  or  the 
radius. 

Fracture  of  both  bones  is  caused  hy  direct  violence,  such  as  a  fall 
or  a  blow,  and  occurs  most  often  in  the  middle  or  lower  sector  of 
the  bones.  Higher  up,  isolated  fracture  of  either  the  ulna  or  the 
radius  is  more  common.  Frac- 
ture of  both  bones  in  the  latter 
situation  is  the  result  of  severe 
direct  violence.  In  children  ni- 
fractions  of  the  bones  of  the 
forearm  are  not  rare. 

Symptoms. —  As  a  rule  the 
deformity-  is  readily  recognized 
by  inspection ;  manipulation  re- 
veals abnormal  mobility  and 
crepitus.  Fractures  near  the 
wrist  and  typical  epiphyseal 
separation  are  discussed  in  ex- 
tenso  farther  on.  When  both 
bones  are  fractured  on  the  same 
level,  the  deformity  is  more 
marked  than  when  each  bone  is 
broken  at  a  different  level.  This 
has  an  important  bearing  on  the 
prognosis.  In  a  similar  sense  it 
is  important  whether  the  lux- 
ation brings  the  fragments  into 
close  lateral  apposition  with 
each  other,  or  whether  there  is 
much  laceration  of  the  interos- 
seous  ligament.      The   latter   is 

attended  with  cicatrical  contracture  and  ossification,  and,  as  the 
bones  are  in  lateral  contact,  hony  coalescence  of  the  parts  in  a  faulty 
position  or  the  formation  of  a  false  joint  in  this  situation  is  very 
likely  to  occur — conditions  which  interfere  with  pronation  and  supi- 
nation (see  Figs.  270  and  271). 

Supracondyloid  fracture  of  loth  hones  of  the  forearm  (Fig.  272) 
merits  especial  mention.     The  lesion  involves  both  diaphyses  near 


Fig.  270. —  Eontgenogram  of  Frac- 
ture OF  Both  Bones  of  Fore- 
arm; Bony  Coalescence  at  Site 
OF  Fracture   (Helferich). 


SPECIAL  FRACTURES 


715 


their  lower  ends  and  is  analogous  to  supramalleolar  fracture  of  the 
bones  of  the  leg.  The  fracture  is  caused  bj^  a  fall  upon  the  hand; 
one  bone  may  be  broken  through  the  diaphysis,  the  other  presenting 
a  simultaneous  epiphyseal  separation.  The  diagnosis  is  readily  made. 
Beposiiion  should  be  accurate.    Fixation  in  supination. 

The  treatment  of  fractures  of  the  forearm  is  an  important  matter. 


B  C 

Fig.  271. —  Fractuke  of  Middle  of  tee  Forearm. 

A,  Typical  deformity  in  fracture  of  the  forearm;  B,  the  radius  is  healed;  the 
ulna  shows  a  false  joint;  C,  the  two  bones  are  healed,  but  a  false  joint  has 
developed  at  the  site  of  the  fracture. 

It  is  necessary  that  union  of  the  fragments  take  place  in  good  posi- 
tion, so  that  the  injury  is  not  followed  by  impairment  of  function. 
In  applying  the  dressing  care  must  b&  taken  not  to  make  circular 
pressure,  which  is  likely  to  bring  the  fragments  into  lateral  contact 
and  encourage  bony  coalescence.  This  means  that  the  use  of  narrow 
splints  must  be  avoided  and  the  fracture  held  in  place  with  splints 
considerably  wider  than  the  forearm.  After  reposition  the  elbow  is 
placed  in  right  angled  flexion  and  the  wrist  is  extended.  The  ques- 
tion of  whether  the  forearm  should  be  pronated  or  supinated  may  be 


716     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


answered  by  stating  that,  since  the  bones  should  not  be  allowed  to 
cross,  and  should  be  held  parallel  to  each  other,  fractures  of  this  sort 
should  be  immobilized  with  the  forearm  in  supination.  Muscular 
action  must  also  be  taken  into  account.  Fig-.  273  shows  the  influence 
of  the  biceps  muscle  on  the  upper  fragment  of  the  radius ;  this  muscle 
supinates  the  bone.  If  the  lesion  were  immobilized  with  the  hand  in 
pronation  and  the  upper  fragment  supinated,  healing  would  be  at- 
tended with  grave  interference 
with  function  (inability  to  supi- 
nate  the  hand).  Angular  de- 
formity of  a  fractured  radius 
always  restricts  its  excursion 
around  the  ulna. 

After  careful  reposition,  the 
forearm  is  immobilized  in  supina- 
tion by  means  of  well  padded 
broad  volar  and  dorsal  splints 
which  include  the  wrist ;  the  hand 
is  left  exposed.  The  dressing  is 
changed  on  the  eighth  day.  If  at 
this  time  angulation  is  present,  it 
may  be  overcome  by  immobilizing 
the  limb  with  the  elbow  extended. 
Passive  motion  and  massage  must 
be  employed  early. 

Fractures  of  the  Ulna. — 
Fractures  of  the  olecranon  (Fig. 
274A)  are  usually  caused  by  a 
fall  upon  the  elbow  (direct  vio- 
lence) ;  at  times  by  the  action 
of  the  triceps  muscle  (avulsion 
fracture)  ;  and  occasionally  by 
overextension  of  the  forearm  (im- 
pingement upon  the  posterior  surface  of  the  end  of  the  humerus). 

Examination  readily  reveals  the  nature  of  the  injury,  which  usually 
consists  of  a  transverse  fracture  at  the  middle  of  the  process.  A 
marked  separation  is  easily  palpated,  and  the  joint  is  usually  filled 
with  a  bloody  exudate.  Active  extension  of  the  flexed  forearm  is 
impossible.    As  a  rule,  the  upper  fragment  can  be  forced  against  the 


Fig.  272. —  Eontgenogram  of  Supra- 
CONDYLOID  Fracture  of  Both  Bones 
OF  THE  Forearm  (Harlem  Hospital 
case). 


SPECIAL  FRACTUKES 


717 


lower  aud  crepitus  elicited.  When  the  periosteum  aud  the  lateral 
fascial  bands  remain  intact,  there  may  be  no  separation  of  the  frag- 
ments. The  latter  contingency  makes  the  prognosis  good;  when, 
however,  there  is  much  diastasis,  bony  healing  is  not  likely  to  occur, 
repair  taking-  place  by  fibrous  union.  This  is,  in  part,  due  to  the  fact 
that  the  articular  surface  is  not  covered  by  periosteum,  nor  its  outer 
aspect  by  the  prolongation  of  the  triceps  tendon,  both  of  which  facts 
make  for  relativeh-  meager  callus  formation. 

Beposition  calls  for  correction  of  the  diastasis.  For  the  purpose, 
the  limb  is  immohilized  with  the  forearm  in  the  fully  extended  posi- 
tion, which  makes  ap- 
proximation of  the 
fragments  possible. 
When  the  distention  of 
the  joint  contributes  to 
the  malposition  it  is 
helpful  to  remove  the 
exudate  by  aspiration. 
The  upper  fragment  is 
held  in  place  by  strips 
of  adhesive  plaster 
which  surround  the 
olecranon  in  the  form 

■n.      o-To      m       T  -r,  Tvr      .^   ^^   ^   sHug   aud   make 

Fig.  273. —  The  Influence  op  the  Biceps  Muscle  ° 

ON   the   Upper   Fragment   in    Fracture   of   the    downward  pressure. 
Shaft  of  the  Eadius.  Primary  suture  of  the 

Supination  of  the  upper  fragment  ■with  the  hand    fragments  is   indicated 
pronated  is  indicated  by  the  rotation  of  the  radial        ,         ,  ^         i         i 

tuberosity.  ^^^^  when  postural  and 

pressure  treatment 
does  not  accomplish  the  purpose.  As  the  fracture  involves  the  joint, 
the  triceps  muscle  is  massaged  early. 

Fracture  of  the  coronoid  process  (Fig.  274B)  is  rare  and  usually 
occurs  in  connection  with  posterior  luxation  of  the  forearm.  The 
influence  of  the  brachialis  anticus  is  only  operative  when  the  frac- 
ture extends  through  the  base  of  the  process,  as  the  muscle  is  at- 
tached to  its  tip.  Isolated  fracture  may  occur  as  the  result  of  violence 
which  forces  the  anterior  surface  of  the  ulna  against  the  lower  end  of 
the  humerus. 

The  symptoms  are  those  of  a  grave  joint  injury.     The  thickness  of 


718     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

the  superimposed  muscles  makes  direct  palpation  of  the  separated 
fragment  impossible.  Careful  palpation  reveals  that  the  bony  promi- 
nences of  the  region  are  normal,  but  that  the  olecranon  process  is 
slightly  displaced  backward  and  may  be  replaced  by  traction  on  the 
forearm.  Backward  and  forward  pressure  upon  the  forearm  may  elicit 
crepitus. 

Beposition  by  traction  upon  the  forearm ;  immobilization  of  the  limb 
in  acute  flexion. 

Fracture  of  the  Upper  Third  of  the  Ulna  With  Luxation  of 
THE    Capitulum   Radii    (Fig.    275). —  In    portions    of    limbs    which 


Fig,  274. —  A,  Influence  of  the  Triceps  Muscle  on  a  Fractured  Olecranon. 
B,  Avulsion  Fracture  of  Coronoid  Process  of  Ulna;  Influence  op 
Brachialis  Anticus  Muscle  on  the  Fragment. 


possess  two  bones  (forearm  and  leg),  certain  findings  are  typical. 
When  both  bones  are  fractured,  malposition  may  be  great  or  slight, 
one  bone  being  displaced  in  proportion  to  the  other.  When,  however, 
only  one  hone  is  broken,  the  other  acts  as  a  splint  and  obviates  great 
malposition  of  the  fragments  of  the  former.  When  a  fracture  of  one 
bone  is  attended  with  great  malposition,  the  unbroken  bone  is  luxated 
in  the  contiguous  joint.     In  this  way,  a  fracture  of  this  sort  is  at- 


SPECIAL  FRACTURES 


719 


tended  with  luxation  of  the  capitulum  radii,  and  a  similar  fracture 
of  the  tibia  is  accompanied  with  simultaneous  luxation  of  the  capi- 
tulum fibulae. 

The  deformation  attendant  upon  fracture  of  the  ulna  in  its  upper 
third,  with  luxation  of  the  head  of  the  radius,  is  a  typical  injury. 
The  symptoms  of  the  fracture  are  very  clear  and  the  diagnosis 
is  self  evident.  However,  the  luxation  of  the  radius  is  often  over- 
looked. Attention  to  the  suggestions  offered  above  should  obviate 
the  error ;  the  degree  of  overriding  of  the  ulnar  fragments  should  sug- 
gest that  the  radius  is  either  fractured  or  dislocated.    Examination  of 


Fig.  275. —  Fracture  of  the  Upper  Third  of  the  Ulna  with  Anterior 
Dislocation  of  the  Capitulum  Eadii. 


the  elbow  joint  reveals  the  absence  of  the  head  of  the  radius  from  its 
normal  position  and  its  presence  in  the  hollow  of  the  elbow,  where  it 
is  readily  palpated,  especially  upon  rotation  of  the  forearm.  As 
reposition  is  easily  accomplished  by  traction  upon  the  hand  and  pres- 
sure over  the  radius,  the  prognosis  is  good  in  correctly  diagnosticated 
cases.  At  times,  the  luxation  at  the  head  of  the  radius  shows  a  ten- 
dency to  recur.  For  this  reason  the  arm  should  be  immobilized  in 
right  angled  flexion,  with  the  forearm  supinated,  and  light  pressure 
made  in  the  hollow  of  the  elbow. 

In  old  unreduced  cases,  osteotomy  at  the  site  of  the  ulnar  fracture, 


720     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


and  arthrotomi)  over  tlie  luxated  radius  are  indicated.     In  some  in- 
stances, it  will  be  found  necessary  to  resect  tlie  head  of  the  radius. 

Fractures  of  the  ulnar  diapliysis  are  often  produced  by  direct 
violence  by  a  fall  upon  the  forearm  or  when  the  flexed  forearm  is  held 
before  the  face  or  over  the  head  for 
protection  (so-called,  "Parry  frac- 
ture"). Occasionally,  the  fracture  is 
caused  by  indirect  ^dolence. 

The  diagnosis,  because  of  the  super- 
ficial location  of  the  ulna,  is  readil}^ 
made  by  palpation.  The  treatment  is 
similar  to  that  of  fractures  of  both 
bones  of  the  forearm  (p.  715). 

Fracture  of  the  styloid  process  of 
the  ulna  alone  is  \eYj  rare,  and  may, 
at  times,  be  diagnosticated  by  accu- 
rate palpation.  Bonj^  repair  does  not 
often  occur.  The  lesion  is  taken  up  in 
connection  with  fractures  of  the  radial 
epiphysis. 

Fractures  of  the  Radius. —  Frac- 
tures of  the  head  and  neck  of  the 
radius  are  rare.  Fracture  of  the  head 
presents  the  clinical  picture  of  a 
joint  injury  and  is  no  doubt  often 
reg'arded  as  such  or  as  a  sprain.  The 
fracture  is  entirelj^  intra-articular 
and  may  be  complete  or  incomplete. 
The  diagnosis  in  the  latter  instance  is 
uncertain.  Complete  fractures  may 
be  recognized  by  the  crepitus  elicited 
upon      pronation      and      supination, 

though  it  is  not  always  pi^esent.  The  Fig.  276.— Eoxtgenogram  of  a 
Rontgenogram  findings  assure  •  the 
diagnosis.  The  lesion  is  usually  caused 
by  a  fall  upon  the  hand  which  results  in  ''chipping"  of  the  edge  of 
the  capitulum  from  impact  against  the  humerus  (so-called,  chisel  frac- 
ture).   A  direct  fracture  of  this  sort  is  possible,  but  rare. 

The  treatment  presents  some  difficulties.    As  direct  influence  upon 


Fracture    of    the    Radial    Dia- 
PHYSis    (Harlem  Hospital  case). 


SPECIAL  FRACTURES 


721 


the  fragment  is  not  possible,  healing  in  malposition  often  results. 
ImmuhiUzation  of  the  joint,  together  with  moderate  pressure  upon 
the  region  of  the  head  of  the  radius  is  indicated.  However,  consider- 
able stiffness  of  the  joint  is  very  likely  to  follow.  In  not  a  few 
cases,  resection  hi  the  head  of  the  bone  becomes  necessary. 

Fracture  of  the  neck  of  the  radius  (i.  e.,  below  the  head)  is  rare. 


Fig.  277. —  Typical  Fracture  of  the  Lower  Eadial  Epiphysis. 

A,  Longitudinal  section  of  the  radius  and  wrist,  the  third  metacarpus  and  the 
third  finger;  B,  the  same  fracture  on  the  living. 


It  is  recognized  by  the  failure  on  the  part  of  the  bone  to  rotate  as  the 
forearm  is  passively  pronated  and  supinated.  The  treatment  is 
similar  to  that  of  fracture  of  the  head  of  the  bone. 

Traumatic  epiphyseal  separation  at  the  upper  end  of  the  radius 
occurs  occasionally  in  children.  The  diagnosis  and  treatment  is 
similar  to  that  pertaining  to  fracture. 

Fracture  of  the  diaphijsis  of  the  radius  (Fig.  276)  does  not 
occur  as  often  as  that  of  the  ulna.  It  is  caused  by  direct  and  indirect 
violence.  The  diagnosis  is  readily  made.  The  malposition  and  the 
treatment  are  taken  up  under  fractures  of  the  forearm. 


722     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

Fracture  of  the  lower  epiphysis  of  the  radius  {Colics'  fracture) 
(Figs.  277  and  278)  is  very  common  and  of  ^reat  importance.  It  is 
attended  with  certain  typical  characteristics  which  are  present  to  a 
greater  or  lesser  extent  in  almost  all  fractures  in  this  situation. 

For  convenience  the  lesion  is  divided  into:  (1)  True  epiphyseal 
separation  (see  below).  (2)  Incomplete  fractures,  fissures,  and  so- 
called  typical  contusions ;  the  latter  are  rare  and  are  usually  com- 
bined with  a  fracture.  (3)  Complete  fractures,  further  subdivided 
into  transverse  and  ohlique.  The  transverse  fracture  involves  the 
entire  thickness  of  the  bone  and  belongs  in  the  group  of  supracondy- 
loid  fractures,  i.  e.,  the  line  of  fracture  is  usually  located  1^2  to  2  cm, 
above  the  lower  articular  surface  at  a  point  where  the  compacta  of  the 


Fig.  278. —  Preparation  of  a  Longitudinal  Section  of  an  .Old 
Fracture  of  the  Lower  Epiphysis  of  the   Eadius,   Show- 
ing THE  Volar  Angulation  and  the  Dorsal  Deformity. 

The  articular  end  is  oblique  to  the  long  axis  of  the  shaft.     The 
old  line  of  the  spongiosa  is  indicated. 


diaphysis  merges  into  the  spongy  area  of  the  articular  region ;  a  situ- 
ation where  the  anatomical  and  mechanical  conditions  favor  the  oc- 
currence of  the  fracture.  The  size  of  the  lower  fragment  varies  be- 
tween forty  and  fifty  mm.  in  height.  The  line  of  the  fracture  is 
usually  nearer  one  side  of  the  joint  surface  than  the  other;  this  is 
determined  by  the  direction  in  which  the  causative  force  is  applied. 
Multiple  or  comminuted  fractures  are  more  common  in  this  situation 
than  was  formerly  believed,  especially  the  Y  fracture  extending  into 
the  joint.  A  certain  number  of  the  fractures  are  ohlique,  the  obliquity 
running  in  various  directions.  Those  extending  from  above  down- 
ward, and  involving  the  joint,  show  a  tendency  toward  obstinate  mal- 
position. 

Avulsion  of  the  styloid  process  is  a  very  common  complication  of 
typical  fracture  of  the  lower  radial  epiphysis  (78  per  cent),  so  that 
this  may  be  regarded  as  a  part  of  the  class  of  fractures  under  discus- 


SPECIAL  FRACTURES 


723 


sion.     At  times  the  process  remains  in  part  attached  to  the  ulna  and 
anlij  presents  a  gaping  space  on  its  ulnar  side. 

The  lesion  is  almost  always  caused  hy  a  fall  upon  the  hand,  usually 
on  its  volar  side.  This  overextends  the  hand  which  is  limited  by  the 
ligaments  on  the  palmer  side  of  the  wrist;  the  ligaments  do  not  tear, 


Fig.  279.- 


DlFFERENTIAL    DIAGNOSIS    OF    FRACTURES    AND    LUXATIONS    OF 

THE  Wrist. 


A-a,  Infraction  of  both  bones  of  the  forearm  in  their  lower  sectors;  J5-&, 
fracture  of  the  lower  radial  epiphysis,  typical  luxation ;  C-c,  dorsal  luxation  of 
the  hand  in  radio-carpal  joint ;  B-d,  dorsal  luxation  of  the  hand  in  the  carpo- 
metacarpal joints  of  the  four  lingers. 


but  the  productive  force  is  expended  upon  the  lower  end  of  the 
radius  which  is  fractured  in  the  location  stated  {avulsion  fracture). 
At  the  same  time,  the  direct  impact  of  the  body  and  a  counter  impact 
from  the  ground  forces  the  upper  row  of  carpal  bones  against  the 
end  of  the  radius,  producing  also  an  angulation  fracture.     However, 


724    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

irrespective  of  the  cliaracter  of  the  causative  mechanism,  the  lesion 
is  always  attended  with  dorsal  displacement  of  the  lower  fragment. 

In  the  comparatively  uncommon  instances  in  which  a  fracture  of 
this  sort  is  produced  by  a  fall  upon  the  back  of  the  hand,  the  lower 
fragment  is  displaced  downward. 


Fig.    280. —  RONTGENOGRAM    OF    TYPICAL    FRACTUKE    OF    THE    LOWEB    END    OF    THE 

Radius,  from  in  Front  (Harlem  Hospital  case). 


The  symptoms  of  this  fracture  must  be  interpreted  by  means  of 
a  systematic  examination  which  begins  with  a  careful  inspection.  For 
the  purpose,  the  surgeon  is  best  seated  opposite  the  patient  who  places 
his  arms  and  elbows  side  by  side.     On  the  injured  side  the  styloid 


Fig.  281. —  Rame  as  Fig.  280,  Viewed  from  the  Side. 

process  of  the  ulna  is  abnormally  prominent ;  the  hand  is  displaced 
toward  the  radial  side.  A  line  corresponding  to  the  long  axis  of  the 
normal  forearm  is  continuous  with  the  middle  of  the  middle  finger; 
on  the  injured  side,  it  ends  on  its  ulnar  side.     The  region  of  the 


SPECIAL  FRACTURES 


725 


styloid  process  is  widened.    All  of  the  symptoms  are  due  to  the  radial 
displacement  of  the  lower  fragment. 

Lateral  inspection  (from  the  radial  side)  of  the  pronated  normal 
forearm  shows  a  slightly  curved  line  with  a  dorsal  concavity  and  a 
volar  concavity.  On  the  injured  side,  this  is  modified  and  is  usually 
reversed,  i.  e.,  an  abnormal  prolusion  is  seen  on  the  flexor,  and  an 
angular  concavity  on  the  dorsal  surface  of  the  lower  portion  of  the 
forearm.  "When  the  long  axis  of  the  forearm  is  outlined  (with  a  blue 
pencil)  its  line  on  the  sound  side  is  straight,  on  the  injured  one  it 
is  broken  and  bent  upward  at  the  fractured  end  of  the  radial  diaphy- 
sis.     This  accentuates  the  bayonet  formed  (silver  fork)  deformity  so 

characteristic  of  this  lesion. 
The  mali^osition  is  the  re- 
sult of  the  unexpended 
causative  force  which  is 
operative  until  the  lower 
end     of     the     diaph^'sis 


Fig.    282. —  Position   in   which   the   Hand   is 
Held  During  Application  of  the  Dressing. 

The  little  finger  is  left  free  with  the  view  of 
obviating  subsequent  pressure   in   this  situation. 


reaches  the  floor.  Muscu- 
lar action,  no  doubt,  also 
contributes  somewhat  to 
the  displacement.  The  mal- 
position is,  however,  not 
alone  backward  and  up- 
ward, but  the  lower  frag- 
ment is  also  slightly  supi- 
nated  while  the  upper 
(radial  diaphysis)  is  pro- 
nated. 

The  other  symptoms  common  to  fractures  are  not  always  manifest. 
Abnormal  niohility  is  usually  slight  and  is  elicited  only  by  grasping 
the  lower  fragment  very  firmly ;  the  same  may  be  said  of  the  crepitus. 
However,  neither  of  these  sj^mptoms  is  necessary  to  diagnosis. 
Points  of  tenderness  are  of  great  value.  In  transverse  fractures  the 
region  of  the  wrist  joint  and  also  that  of  the  styloid  process  of  the 
ulna  are  not  tender  upon  pressure,  but  palpation  of  the  zone  one  to 
two  cm.  above  these  points  causes  considerable  pain.  In  addition  to 
this,  palpation  verifies  the  deformity  found  on  inspection. 

The  diagnosis  is,  as  a  rule,  made  on  inspection  and  comparison  with 
the  sound  side.  The  differential  diagnosis  is  important.  The  rela- 
tionship of  the  styloid  process  to  the  most  painful  area,  and  the  de- 


726     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


formity,  are  of  diagnostic  value.  Differentiation  from  luxation  at 
the  wrist  is  not  a  difficult  probleaa ;  on  the  other  hand,  great  swelling 
and  pain  make  differentiation  of  infraction  from  so-called  "typical 
contusion^'  of  the  lower  radial  epiphysis  difficult.  The  Rontgeno- 
graphic  examination  clears  up  the  question  with  respect  to  infraction 
and  "incomplete  infraction." 

The  prognosis  is  greatly  dependent  upon  the  treatment ;  when  this 
is  properly  carried  out,  return  to  the  normal  is  possible. 

Reposition  is  accomplished  by  traction  and  forced  flexion  (volar 
flexion)  of  the  hand  (forced  formation  of  a  fist).  Narcosis  is  desir- 
able. When  the  fracture  is  not  recent  and  the  luxation  is  great,  it 
is  well  to  execute 
preliminary  dorsal 
flexion  of  the  hand, 
which  releases  the 
lower  fragment,  and 
makes  reposition  as 
stated. 

The  dressing  should 
include  the  entire 
forearm,  the  wrist 
and  the  middle  of 
the  hand.  The  elbow 
joint  and  the  fingers  yig.  283.— Application  of  a  Molded  Gypsum  Splint, 
should   not   be   fixed  •       Using  the  Patient  's  Thigh  as  a  Best,  and  the 

'        Bend  of  the  Knee  to  Maintain  the  Eeposition. 
immobilzation  of  the 

latter    is    often    followed    by    permanent    restriction    of    motion. 

In  order  to  maintain  the  distal  fragment  in  proper  position,  the 
hand  must  he  fixed  in  decided  volar  flexion,  and  must  be  inclined 
toward  the  ulna;  in  addition  to  this,  the  hand,  as  a  whole,  must  be 
pushed  toward  the  ulna  with  the  view  of  obviating  protrusion  of  the 
styloid  process  of  the  latter. 

The  material  used  for  fixation  is  not  of  importance.  A  gypsum 
dressing,  extending  from  the  heads  of  the  metacarpal  bones  to  the 
elbow,  as  shown  in  Fig.  283,  or  a  splint,  as  shown  in  Fig.  291,  answers 
the  purpose.  When  a  dressing  is  improvised  from  pasteboard  or 
wood,  the  ulnar  flexion  is  maintained  by  the  form  of  the  splint  (pistol 
splint),  and  a  soft  pad  is  placed  beneath  the  lower  end  of  the  diaphy- 
sis  Avith  the  view  of  elevating  it,  and  allowing  the  epiphyseal  frag- 
ment to  sink  into  position.    The  treatment  of  fractures  of  this  sort  by 


SPECIAL  FKACTURES 


727 


slinging  the  forearm  and  allowing  the  hand  to  hang  down  may  be  used 
when  the  deformity  shows  no  tendency  to  recur.  However,  the 
method  is  not  without  a  certain  danger  and  ha.s  a  restricted  field  of 
application.  A  neat  dressing  is  shown  in  Fig.  284.  The  method  per- 
mits of  earl}^  massage  (second  da}'),  the  application  of  heat  and  the 
use  of  passive  motion.  In  cases  in  which  the  displacement  shows  a 
tendency  to  recur  despite  the  use  of  the  methods  of  fixation  stated,  the 
dressing  shown  in  Fig.  285  will  be  found  useful.     The  splint  is  so 


Fig.  284. —  A,  Showing  the  Use  of  a  Simple  Eoller  Bandage  in  the  Treat- 
ment OF  TYPicAii  Fracture  of  the  Lower  End  of  the  Eadius;  B,  Show- 
ing THE  Application  of  the  Second  Layer  of  Bandage,  with  Turn  No. 
2  Omitted. 


padded  as  to  flex  the  lower  fragment  toward  the  volar  side  of  the 
forearm. 

It  is  necessary  to  remember  that  a  fracture  extending  into  the  joint 
is  being  dealt  with,  and  that  frequent  changes  of  the  dressing,  early 
massage,  and  the  prompt  use  of  passive  motion  are  essential  to  return 
of  function.  When  the  styloid  process  of  the  ulna  is  avulsed,  the 
radio-ulnar  joint  and  the  wrist  are  both  involved  in  the  injury.  It  is 
better  to  obtain  return  of  function  with  slight  deformity  than  healing 
with  perfect  alignment  of  the  fracture  and  loss  of  function.     In  a 


728     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

certain  number  of  cases  it  is  necessary  to  resect  the  styloid  process 
in  order  to  improve  the  mobilitj^  of  the  joint. 

Separation  of  the  lower  epiphysis  of  the  radius  occurs  in  youngj 
persons.  The  symptoms  and  treatment  are  similar  to  those  of  fracture 
in  this  situation.  After  repositioji  there  is  rarely  any  tendency  to 
recurrence  of  the  deformity. 

Fractures  of  the  Hand  and  lingers. — Fractures  of  the  carpal  bones 
are  uncommon  and  usually  occur  in  connection  with  severe  lacera- 
tions of  the  soft  parts.  The  degree  of  involvement  is  indicated  by  the 
extent  of  the  injury  to  the  latter.  However,  the  advent  of  the  Ront- 
genogram  has  shown  that  fractures  of  this  sort  are  more  frequent  than 
was  formerly  believed. 


Fig.  285. —  Dressing  for  Fractures  of  the  Lower  End 
OP  the  Eadius  which  Show  a  Tendency  toward  Ee- 
currence  of  the  Malposition. 


Fractures  of  the  Metacarpal  Bones. — These  are  not  rare  and  are 
caused  by  a  blow  on  the  hand,  or  by  the  hand  striking  a  hard  sub- 
stance. As  a  rule,  a  false  point  of  motion  and  crevitus  may  be 
elicited.  Usually,  there  is  no  luxation  of  the  fragments.  In  most 
cases,  carrying  the  hand  in  a  sling  is  all  that  is  necessar}^  When  there 
is  much  displacement,  ojjen  reduction  is  indicated. 

Fractures  of  the  Fingers. — Fractures  of  the  phalanges  are  usu- 
ally caused  by  direct  violence ;  thus,  oblique  fractures  are  very  com- 
mon. Avulsion  fractures  of  the  distal  phalanges,  due  to  forcible 
traction  of  the  flexor  tendons,  have  been  observed.  The  diagnosis  is 
made  by  means  of  the  Rontg-enogram.  The  treatment  consists  of 
fixation  by  the  application  of  a  narrow  splint. 


SPECIAL  FRACTURES 


729 


FRACTURES  OF  THE  LOWER  EXTREMITY. 

Fractures  of  the  Pelvis  (1  per  cent  of  all  fractures)  (Fig.  288). — 
A  solution  of  continuity  of  the  pelvis  is  usually  the  result  of  great 
force.  The  significance  of  the  injury  lies  in  the  damage  to  the  skeletal 
mechanism  and  in  the  complicating  injuries. 

It  has  been  customary  to  describe  separation  of  the  s^nnphysis  pubis 
and  of  the  sacro-iliac  articulations  as  luxations;  however,  the  work 
of  Stolper^"  would  seem  to  indicate  that  this  possesses  no  practical 

value,  especially  as 
in  both  instances 
spicula  of  bone  are 
always  avulsed  and 
the  bones  are  more 
or  less  fissured  in 
this  class  of  cases. 
Stolper^''  suggests 
that  thej^  be  called 
"luxation  frac- 
tures." 

Clinically,  frac- 
tures of  the  pelvis 
are  best  divided 
into  those  in  which 
a  part  of  the  pelvic 
brim  is  broken  — 
so-called  fracture 
of  the  pelvic 
brim  —  and  into 
those  involving  the 
bones  forming  the 
ring  of  the  pelvis  —  the  -so-called  fractures  of  the  pelvic  ring. 
The  occurrence  of  the  one  or  the  other  form  of  fracture  is  deter- 
mined by  the  character  of  the  causative  force.  Fractures  of  the  pelvic 
hrim  are  the  result  of  direct  violence,  those  of  the  ring  are  caused  by 
indirect  violence,  such  as  compression  force  in  which  the  ring  gives 
way  at  an  arched  area,  usually  in  more  than  one  place. 

The  fractures  of  the  pelvic  hrim  which  result  from  direct  violence 
(hoof  kick,  fall  from  a  height,  impact  of  a  falling  tree,  crushing  by  a 


Fig. 


186. — RONTGEXOGRAM    OF    HeALED    FRACTURE    OF    THE 

Fifth  Metacarpel  Bone. 


730     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


wagon  wheel,  etc.)  may  be  divided  into  the  following  classes   (Stol- 
per'°)  : 

1.  Isolated  fracture  of  the  wing  of  the  ilium  (for  instance,  by  a 
hoof  kick). 

2.  Transverse  fracture  of  the  sacrum,  produced  by  a  fall  from  a 
height. 

3.  Single  or  douhle  fracture  of  the  pubic  hone,  i.  e.,  of  either  or 
both  rami.    This  injury 
is  often  complicated  by 
laceration    of    the    ure- 
thra. 

An  especial  form  of 
avulsion  fracture  of  the 
crest  of  the  ilium  may 
be  caused  by  muscular 
action. 

Fractures  of  the  pel- 
vic ring  may  be  irregu- 
lar in  form :  however,  as 
a  rule,  the  true  pelvis 
is  fractured  as  a  result 
of  a  force  which  deforms 
it  as  a  whole  (Stolper^-). 
The  pelvis  is  compressed 
in  its  frontal,  its  sagit- 
tal, or  its  oblique  diam- 
eter, and  when  the  limit 
of  its  "  bending  capac- 
ity "  is  reached  it  frac- 
tures, usually  in  more 
than  one  place.  The 
"  double  vertical  frac- 
ture," shown  in  Fig. 
288,  belongs  to  this  class 

of  cases.  The  location  and  the  direction  of  the  lines  of  fracture, 
and  of  the  fissures,  vary  in  accord  with  the  direction  of  the  pressure 
and  counterpressure,  which  may  be  frontal,  sagittal,  equatorial,  or  in 
the  short  diameter  of  the  pelvic  ring.  Of  course  the  varying  resist- 
ance of  the  several  sectors  of  the  pelvis  also  comes  into  play,  so  that, 


Fig.     287. —  EONTGENOGRAM     OF    AN    ObLIQUE    FRAC- 
TURE OF  THE  Thumb  (Harlem  Hospital  case). 


SPECIAL  FRACTURES 


731 


almost  irrespective  of  the  direction  of  the  provocative  compressing 
force,  the  rami  and  the  body  of  the  pubis  are  most  often  broken.  As 
fractures  in  the  latter  region  are  always  attended  with  considerable 
splintering,  the  urethra  and  the  bladder  are  very  likely  to  ie  injured. 
In  addition  to  this,  the  acetabulum  is  very  often  fissured. 

A  combination  of  fracture  of  the  pelvic  brim  and  the  ring  may  also 
occur. 

The  examination  and  dia{;nosis  in  fractures  of  the  pelvis  include 
taking  into  account  the  character  of  the  injury  and  the  presence  of  a 
contusion  in  this  region.  In  not  a  few  instances,  especially  when  the 
patient  is  confined  for  a  considerable  period  of  time  following  a  severe 

injury,  a  fracture  of  the  pelvis  is 
not  suspected  until  he  leaves  the 
bed. 

In  recent  cases,  careful  palpation 
of  the  bones  of  the  pelvis  (the  tuber- 
osities of  the  ischii,  the  rami,  and 
the  bodies  of  the  pubes)  should  be 
employed.  The  crests  of  the  ilii 
should  be  compressed  between  the 
hands;  this  often  makes  localization 
of  the  pressure  pain  possible  and 
may  demonstrate  a  false  point  of 
motion  or  crepitus. 

On  the  whole,  the  prognosis  is  de- 
termined  by  the   complications;   in 
their  absence,  the  outlook  is  favor- 
able.    The  following  complications 
are  to  be  considered. 
DccoUement  traumatique  with  mostly  bloody  lymph  extravasation, 
when  the  force  is  tangential  (especially  when  the  patient  has  been  run 
over). 

Hemorrhage  into  the  musculature  within  the  pelvis. 
Fat  emoolism  (pulmonary). 
Laceration  of  the  veins  of  the  pelvis. 
Injuries  to  arteries  and  nerves  (rare). 

Injuries  of  the  urethra,  especially  when  the  patient  falls  astride  a 
hard  object.  Injuries  of  this  nature  are  divided  into  penetrating 
(when  blood  flows  from  the  urethra)  and  nonpenetrating.  Urethral 
bleeding,  or  hematuria,  is  always  a  grave  sign.     The  danger  of  extrav- 


FiG.  288. —  The  So-called  Double 
Vertical  Fracture  of  Malg^ugne 
caused  by  a  crushing  injury. 

In  front,  the  pelvis  is  fractured  on 
either  side  of  the  symphysis  in  the 
region  of  the  bones  bounding  the  ob- 
turator foramen.  Behind,  the  ilium 
is  fractured  close  to  the  sacroiliac 
articulation. 


732    INJURIES  TO   SOFT  PARTS,  BONES  AND   JOINTS 

asation  of  urine  is  as  great  in  eases  of  a  small  tear  in  the  urethra  as 
it  is  when  the  urethra  is  completely  torn  across.  In  these  eases  the 
expectant  treatment  is  to  be  condemned.  External  urethrotomy 
should  be  speedily  performed. 

The  urinary  bladder  may  be  injured  by  a  sharp  fragment  of  bone 
or  ruptured  (when  full)  by  the  compressing  force  without  the  occur- 
rence of  a  fracture.  In  these  cases,  the  patient  is  catheterizcd,  the  urine 
(if  any)  is  withdrawn  and  its  character  noted.  A  measured  quantity 
of  urine  is  then  injected,  and  if  this  does  not  return  in  full,  the 
diagnosis  of  rupture  of  the  bladder  is  permissible. 

The  recognition  of  old  fractures  of  the  pelvis  is  an  involved  prob- 
lem. The  Rontgenogram  is  likely  to  be  helpful.  Clinically,  all  the 
available  protrusions  must  be  carefully  palpated,  to  which  is  added 
the  interpretation  of  function — hindrance  in  abduction  and  adduction 
of  the  limbs,  careful  inspection,  measurements,  bony  thickening,  etc. 

In  fresh  cases,  with  upward  displacement  of  half  of  the  pelvis, 
traction  on  the  leg  of  the  affected  side  reduces  the  deformity.  The 
patient  should  be  placed  on  a  water  bed  and  the  pelvis  firmly  strapped 
with  adhesive  plaster  or  other  suitable  material.  When  the  acetabu- 
lum is  involved,  early  passive  motion  of  the  hip  joint  is  indicated. 

Fractures  of  the  Femur  (12.6  per  cent  of  all  fractures). —  Fractures 
of  the  upper  end  of  the  femur  are  classified  as  those  of  the  head,  of 
the  neck  and  of  the  trochanteric  region.  The  nech  lies  between  the 
edge  of  the  articular  cartilage  and  the  trochanters.  The  trochanters 
are  connected  in  front  by  the  intertrochanteric  line,  behind  by  the 
crista  intertrochanterica.  The  capsular  ligament  of  the  hip  joint 
incloses  not  only  the  head  of  the  bone,  but  also  a  considerable  extent 
of  the  neck.  In  front,  it  extends  to  the  intertrochanteric  line ;  behind 
it  reaches  the  middle  of  the  neck.  The  trochanters  and  the  portion  of 
the  shaft  immediately  below  them  are  also  included  in  the  upper  end 
of  the  femur. 

Fractures  of  the  Upper  End  of  the  Femur. —  Fractures  of  the 
upper  end  of  the  femur  are  caused  in  several  ways.  Those  of  the 
head  and  neck  (other  than  perforating  fractures,  such  as  gunshot 
wounds)  are  the  result  of  indirect  violence.  Those  in  the  region  of 
the  trochanters  and  in  the  inf  ratrochanteric  region  may  be  the  outcome 
of  direct  violence  by  bending,  torsion,  compression,  and  of  indirect 
violence  by  overextension  or  rotation  of  the  femur. 

From  an  anatomical  standpoint  fractures  of  the  upper  end  of  the 
femur  are  divided  into : 


SPECIAL  FRACTURES 


733 


Fig.  289. —  A,  Impacted  Intracapsular  Frac- 
ture AXD  THE  XORMAL  OUTLINE  OF  THE  BONE. 

The  neck  of  the  bone  is  shortened. 

B,  A  Frontal  Section  of  A. 

C,  D,  False  Joint  at  the  Seat  of 
an  Intracapsular  Fracture. 

The  neck  of  the  bone  has  almost  entirely  dis- 
appeared (friction  absorption).  The  head  of 
the  bone  is  fixed  in  the  aceiabulum. 


1.  Traumatic  e  p  i  - 
physeal  separation  at 
the  upper  end  of  the 
femur  (epiphyseal  frac- 
ture). 

2.  Intracapsular  frac- 
ture of  the  neck  of  the 
femur;  the  line  of  frac- 
ture is  close  to  the  head 
of  the  bone. 

3.  Extracapsular 
fracture  of  the  neck  of 
the  femur;  the  line  of 
fracture  is  close  to  the 
trochanter. 

4.  Fractures  of  the 
femur  in  the  region  of 
the  trochanters  (troch- 
anteric fracture). 

5.  Isolated  fracture 
of  the  trochanter  major. 

6.  Fracture  of  the 
femur  in  the  upper  por- 
tion of  the  shaft  close  to 
the  trochanters. 

Fractures  of  the 
Neck  of  the  Femur. — 
These  are  relatively  fre- 
quent. Those  regarded 
as  intracapsular  and 
extracapsular,  from  a 
theoretical  standpoint, 
cannot  be  definitely  sep- 
arated into  such.  The 
line  of  fracture  is  not 
always  transverse  and 
its  relationship  to  the 
capsule  varies  in  differ- 
ent cases,  nor  is  this  im- 


734    INJURIES  TO   SOFT  PARTS,  BONES  AND   JOINTS 

portant.  The  so-called  extracapsular  fracture  often  invades  the 
intracapsular  zone  of  the  bone,  especiallj^  because  the  capsule  (as 
alread}'  stated)  extends  to  the  intertrochanteric  line  in  front.  The 
"extracapsular"  fractures  of  most  authors  are  really  mixed,  i.  e., 
partly  intra-  and  partly  extracapsular. 
Helf erich-*  suggests  an  anatomical  characterization  as  follows : 


Fig.  290. —  Eontgenogram  of  Medial  Fracture  of  the 
Neck  of  the  Femur   (Harlem  Hospital  case). 


Medial  (or  proximal)  and  lateral  (or  distal)  fractures  of  the  neck 
of  the  femur. 

In  the  medial  fracture  the  solution  of  continuity  of  bone  corresponds 
to  the  middle  sector  of  the  neck  of  the  femur  near  its  head  and  is  often 
entirely  intracapsular.  The  fragments  consist  of  the  femur  and  the 
neck  on  the  one  side  and  the  separated  head  on  the  other.  The  head 
of  the  bone,  which  is  nourished  mainly  b}^  the  periosteum  and  by  the 
blood  supply  derived  from  the  neck,  would  be  entirely  without  suste- 
nance were  it  not  for  the  vessels  in  the  ligamentum  teres.     The  latter 


SPECIAL  FRACTURES 


735 


are,  however,  very  meager,  especially  in  old  persons,  and  the  separated 
caput  femoris  is  very  likely  to  occupy  a  position  analogous  to  a  joint 
mouse. 

In  the  lateral  fracture  the  line  of  separation  is  in  the  outer  aspect 
of  the  neck  of  the  femur  near4he  trochanters  and  is,  at  times,  extra- 
capsular, but,  as  a  rule,  a  portion  of  it  is  extracapsular  while  the  other 
is  intracapsular  (mixed  fractures).  The  upper  fragment  consists  of 
the  head  and  neck  and  is  well  supplied  with  nourishment  by  the  intact 
capsule  and  by  the  periosteum. 

The  etiology  of  fractures  of  the  neck  of  the  femur  is  practically 

limited  to  indirect 
violence.  Two  kinds 
of  force  have  to  be 
taken  into  account: 
Either  a  fall  upon 
the  knee  (at  times 
upon  the  foot  with 
the  leg  extended)  in 
which  the  impact  is 
t  r  a  n  s  m  i  1 1  e  d  by 
means  of  the  shaft 
to  the  neck  of  the 
bone.  As  the  head  is 

Fig.    291. —  A,    Impacted    Extracapsular     (Lateral)    fixed    in    the    aceta- 
Fracture  of  the  Neck  of  the  Femur.     The  impac-    ,     , 

tion  is  into  the  trochanter.     The  neck  of  the  bone  is    DUlum,    COUnterpres- 
shortened  and  is  at  right  angles  to  the  shaft.  SUre     is     made     and 

B,  Section  op  A.     The  normal  position  of  the  bone  is    ,,       „  .  , 

outlined.  t^e  force  is  expend- 

ed upon  the  neck  of 
the  femur  and  a  medial  (bending)  fracture  is  produced. 

Or  a  fall  upon  the  trochanter  major,  i.  e.,  on  the  side  of  the  body  in 
which  the  weight  of  the  falling  body  strikes  the  ground  and  com- 
presses the  neck  between  the  trochanter  and  the  head.  The  compres* 
sion  leads  to  a  fracture  where  the  compact  and  the  thinner  portion 
of  the  neck  of  the  femur  merges  into  the  thicker  and  spongy  tissue  of 
the  region ;  a  fracture  occurs  at  the  border  of  the  neck  and  head,  or  at 
the  border  of  the  neck  and  the  trochanter.  In  other  words,  a  medial 
or,  as  a  rule,  a  lateral  fracture  of  the  neck  of  the  femur  is  produced. 
These  fractures  are  designated  as  compression  fractures  and  are  often 
impacted. 


736    INJURIES  TO   SOFT  PARTS,  BONES  AND  JOINTS 

It  is  probable  that  the  neck  of  the  femur  may  be  fractured  by 
forcibly  bending  the  trochanter  backward ;  however,  this  must  be  rare. 

In  the  lateral  fractures  of  the  neck  of  the  femur,  the  line  of  separa- 
tion extends  into  the  trochanteric  zone.  In  a  reversed  way,  fractures 
of  the  trochanteric  area  may  extend  into  the  neck ;  practically,  these 
cannot  be  differentiated  from  lateral  fractures. 

The  frequency  with  which  these  fractures  occur  in  old  persons  is 
explained  on  the  ground  of  the  friability  of  the  bones  in  this  situation 
in  advanced  life.  Under  ordinary  conditions,  the  upj^er  end  of  the 
femur  is  of  necessity  very  resistant,  as  it  is  concerned  in  carrj'ing  the 
weight  of  the  body.  As  age  advances,  the  changes  in  the  character 
of  the  bony  structure  (loss  of  organic  constituents)  take  on  the  form 
of  an  osteoporosis  which  is  greater  in  women  than  in  men;  this 
explains  the  frequency  of  the  lesion  in  women. 

'  In  addition  to  this,  the  angle  of  the  neck  to  the  shaft  of  the  femur 
is  not  always  the  same.  The  nearer  this  relationship  is  to  a  right 
angle,  the  more  is  force  directed  upward  from  the  foot  likely  to  result 
in  fracture  above  the  intertrochanteric  line. 

The  medial  fractures  are  the  less  frequent ;  they  may  be  loose  or 
impacted.  Bony  union  is  uncommon  and  only  happens  when  the 
upper  fragment  is  nourished  by  periosteum.  As  a  rule,  a  pseudo- 
arthrosis is  formed.  When  the  patient  walks  about,  the  lower  frag- 
ment is  caused  to  glide  upw^ard  and  downward  upon  the  upper  one 
and  a  smooth  surface  is  created  upon  the  latter.  The  head  of  the  bone 
becomes  fixed  in  the  acetabulum  by  fibrous  or  bony  adhesions. 

Lateral  fractures  are  much  more  common  and  are  usually  impacted. 
Bony  union  is  the  rule  and  may  occur  without  treatment.  The  forma- 
tion of  callus  is  ample.  An  impacted  fracture  may  be  liberated  by 
forcible  manipulations,  or  when  the  patient  walks  about  too  early 
without  adequate  protection.  Thus  moderate  displacement  may 
become  great. 

Bej'ond  the  vertical  displacement,  fracture  of  the  neck  of  the  femur 
is  attended  with  outward  rotation  in  almost  all  instances.  This  may 
occur  in  the  presence  of  impaction  and  may  be  the  only  s3'mptom. 
Most  observers  regard  this  sjinptom  as  simpl}^  ''helpless  eversion;" 
however,  it  has  been  shown  that  the  neck  of  the  femur  is  weakest  at 
its  posterior  aspect  and  that  this  is  likely  to  be  most  severely  injured 
when  trauma  is  directed  against  the  trochanter  (Kocher^^). 

This  may  also  be  applied  to  incomplete  fractures  of  the  neck  of  the 
femur  (infractions)  occurring  in  the  medial  and  lateral  sectors  of  the 


SPECIAL  FRACTURES 


737 


bone,  which  result  from  bending  of  only  one  side  of  the  neck  (above 
and  behind),  and  are  attended  with  partial  impaction.  In  this  way 
the  neck  of  the  femur  may  underg-o  considerable  shortening  and  some 
modification  of  its  angle  to  the  shaft. 

Symptoms. —  When  an  elderl}-  person  falls  upon  the  knee  or  on  the 
side  and  is  unable  to  walk,  and  w^hen  the  injured  limb  is  shortened 
and  rotated  outward,  fracture  of  the  femur  must  always  be  given 
serious  consideration.  The  differential  diagnosis  must  take  into 
account  a  sprain,  a  contusion,  a  luxation  of  the  hip,  and  a  fracture  of 
the  pelvis.  The  only  luxation  attended  with  outward  rotation  is  the 
anterior,  and  confusion  in  this  connection  is  unthinkable.     The  patient 

is  unable  to  elevate  the  in- 
jured limb,  i.  e.,  active 
tlexion  of  the  hip  joint  is 
lost ;  the  limb  lies  quietly  in 
the  extended  position  with- 
out abduction  or  adduction. 
Palpation  of  a  fracture  in 
this  situation  is  only  possible 
when  the  trochanter  is  in- 
volved, and  even  then  is 
rarely  attainable. 
^  Shortening  of  the  femur, 

-^  as  a  whole,  is  present  when 

Fig.  292. —  External  Rotation  of  the  Femur  the  neck  is  fractured    even 
iisr  Intracapsular   (Medial)    Fracture  of    ,,  i     ^i        r.       ,  '•      • 

TWF.  MFPTf  OF  THF.  vfatttr  though   thc   tracturc   is   in- 

complete or  impacted.  The 
recognition  of  shortening  by 
means  of  measurement  is  not 
without  its  problems.  This  is  due  to  the  difficulties  encountered  in 
posturing  the  patient  symmetrically,  especiall}-  because  the  neck  of 
the  bone  is  flexed  in  the  hip  joint  and  the  pelvis  is  tilted.  The  meas- 
urements should  encompass  the  distance  between  the  anterior  superior 
spine  of  the  ilium  and  the  line  of  the  knee  joint  or  the  lower  end  of 
the  patella.  However,  both  the  tape  and  the  ej^e  usually  note  the 
shortening. 

The  elevated  position  of  the  trochanter  is  of  great  diagnostic  signifi- 
cance. This  is  to  be  determined  in  the  manner  described  in  connec- 
tion with  posterior  dislocations  of  the  hip  joint  (p.  625).  The  pres- 
ence of  the  tip  of  the  trochanter  above  the  Roser-Nelaton  line  shows 


THE   XECK   of   the   FeMUR. 

A,  Front  view. 

B,  Posterior  view. 


738     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


that  the  rest  of  the  femur  is  intact  and  that  the  cause  of  the  shorten- 
ing lies  in  the  neck  of  the  femur  or  in  the  hip  joint.  This  symptom 
must  be  compared  to  the  conditions  in  this  respect  on  the  other  side 
of  the  body.  The  shortening  is  due  to  displacement  of  the  fragments, 
which  occurs  at  the  time  the  injury  is  received  and  is  maintained  by 
the  drag  of  the  muscles  upon  the  shaft  of  the  femur. 

The  trochanter  is  displaced  inward  as  the  result  of  the  shortening 
of  the  neck  of  the  femur.  Unfortunately,  this  cannot  be  demonstrated 
by  measurement  but  may  be  appreciated  hy  the  eye. 

The  injured  limb  may  be  moved 
in  all  directions  (though  this  is 
painful).  When  the  fragments 
are  in  contact  with  each  other, 
crepitus  may  be  elicited  in  this 
way.  The  radius  of  rotation  on 
the  injured  side  is  less  than  that 
on  the  uninjured,  i.  e.,  in  the  ab- 
sence of  impaction. 

Impacted  fractures  of  the  neck 
of  the  femur  are  also  readily 
recognized.  Shortening  and  ex- 
ternal rotation  is  always  present. 
Both  of  these  are  less  marked  than 
obtains  in  complete  loose  frac-  Fig. 
tures.  Crepitus  is  absent  and  mo- 
tion in  the  hip  joint  is  more  or 
less  free.  The  patient  is  able  to 
invert  the  limb. 

When  an  impacted  fracture  be- 
comes ' '  loose, ' '  the  history  of  the 

case  is  very  characteristic.  As  a  rule,  the  patient  is  able  to  go  about 
(though  with  much  discomfort)  after  the  injury.  Suddenly,  during 
an  unimportant  motion,  severe  pain  is  experienced  in  the  region  of 
the  hip  joint  and  the  clinical  picture  of  complete  fracture  of  the  neck 
of  the  femur  is  presented. 

Incomplete  fractures  of  the  neck  of  the  femur  (infraction)  cannot 
be  differentiated  from  the  impacted.  They  are  attended  with  eleva- 
tion of  the  trochanter  and  a  certain  degree  of  external  rotation,  the 
result  of  solution  of  continuity  of  the  posterior  aspect  of  the  neck  of 
the  bone   (see  above),  which  is  more  vulnerable  than  the  anterior. 


293. —  Displacement  Upward  op 
THE  Trochanter  in  Fracture  of  the 
Xeck  of  the  Femur  Seen  from  Be- 
hind. 

The  location  of  the  anterior  spines  and 
of  the  tips  of  the  trochanters  is  indi- 
cated by  straight  lines  ■which  demon- 
strate  the   shortening. 


SPECIAL  FRACTURES  739 

The  term  coxa  vara  has  been  applied  to  the  changes  in  the  upper  end 
of  the  femur  consequent  to  various  lesions,  i.  e.,  medial  and  lateral 
fractures,  epiph^'seal  separations,  and  fractures  of  the  trochanter. 

As  the  injury  frequently  occurs  in  elderly  persons,  the  general  care 
of  the  patient  is  important.  The  occurrence  of  a  hypostatic  pneumo- 
nitis often  results  in  a  fatal  outcome;  therefore,  careful  feeding,  fre- 
quent change  of  posture,  and  breathing  exercises  should  be  ordered. 
In  this  class  of  cases  the  employment  of  ambulatory  splints  is  of  value 
(p.  750). 

As  a  rule,  lateral  fractures  heal  with  the  formation  of  abundant 
callus.  On  the  other  hand,  in  fractures  of  the  medial  variety,  bony 
union  is  rare  and  the  formation  of  a  pseudo-arthrosis  is  common. 
The  false  joint  is  created  by  "friction  sliding"  between  the  fixed  head 
and  the  lower  fragment.  When  an  impaction  or  a  partial  fracture 
in  this  situation  is  diagnosticated,  motion  is  restricted  until  union 
takes  place;  however,  refracture  may  occur  weeks  after  the  original 
injury.  In  these  cases  the  use  of  an  ambulatory  splint  is  also 
indicated. 

The  extension  dressing  is  largely  used  in  connection  with  fractures 
of  the  neck  of  the  femur  and  is  for  this  reason  fully  described  at  this 
time.  It  is  also  indispensable  in  cases  of  fracture  in  other  situations, 
in  which  but  little  modification  of  the  technic  is  necessary.  It  is  the 
duty  of  all  practitioners  to  be  familiar  with  the  principles  underlying 
its  use,  and  the  mode  of  its  construction  and  application.  The  appa- 
ratus origmated  in  the  United  States  of  America  (Buck^-)  and  was 
used  in  connection  with  fracture  by  v.  Volkmann,  who  perfected  it 
by  the  simultaneous  use  of  the  "sliding  footboard." 

The  original  principle  of  the  measure  involved  the  application  of 
traction  to  the  injured  limb  below  the  site  of  the  fracture.  For  the 
purpose  two  strips  of  plaster  were  applied  to  the  surface  of  the  injured 
limb  in  its  longitudinal  direction  and  held  in  close  apposition  by  means 
of  additional  strips  applied  in  circular  fashion.  The  lower  ends  of 
the  longitudinal  strips  were  united  by  means  of  a  "spreader"  of  wood 
to  which  a  cord  was  attached  and  from  the  latter  a  weight  (20  kilo) 
was  suspended.  The  plaster  strips  must  be  smoothly  applied,  the 
knee  and  foot  are  left  free,  the  foot  is  so  postured  on  the  sliding  foot 
rest  that  no  pressure  is  made  upon  the  heel,  and  the  cord  is  led  over  a 
pulley  fastened  to  the  end  of  the  bed. 

Bardenheuer^^  modified  the  original  apparatus.  The  chief  points 
in  this  connection  would  seem  to  be  that  he  extends  the  lateral  longi- 


740     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

tudinal  traction  strips  to  beyond  the  seat  of  the  fracture  and,  instead 
of  using  the  circular  strips  for  holding  the  former,  he  applies  them 
in  a  systematic  maimer  with  the  view  of  preventing  lateral  and  rotary 
displacement  of  the  fragments.  He  also  replaces  the  sliding  foot 
board  with  a  rod  placed  above  the  patient  and  fastened  to  the  bed, 
from  which  the  limb  may  be  suspended. 

In  this  way  the  musculature  of  the  injured  limb  is  entirely  unbur- 
dened and  the  overriding  of  the  fragments  in  fractures  of  the  sliafts 
of  the  bones  is  overcome.  The  particular  displacement  is  overcome 
by  the  adjustment  of  the  strips  which  make  lateral  or  rotary  traction; 
however,  this  action  is  effectual  only  when  longitudinal  traction  or 


Fig.   294. —  Bardenheuer 's  Extension   Apparatus. 

a,  The  longitudinal  bands  of  plaster.  The     weights  overcome  the 
shortening,  the  dropping  of  the  foot,  and  the  rotation  of  the  limb. 


extension  is  sufficient  to  overcome  the  overriding.  By  suspending  the 
injured  limb  by  means  of  one  or  two  strips  fastened  to  pulleys  above 
the  patient,  certain  parts  of  the  former  become  accessible  to  inspection 
and  passive  motion,  and  secondary  displacement  becomes  instantly 
amenable  to  correction. 

The  use  of  this  sort  of  apparatus  is  also  taken  up  with  the  treatment 
of  other  fractures  in  which  it  is  indicated.  In  this  connection  the 
description  is  limited  to  the  general  technic  of  the  application  of 
extension  to  the  lower  limb. 

For  the  purpose,  rubher  plaster  or,  when  a  heavy  weight  is  used, 
canvas  fastened  with  an  adhesive  paste  is  employed.     The  newer,  non- 


SPECIAL  FRACTURES 


741 


irritating  plaster  strips  are  made  of  sailcloth,  one  side  of  which  is 
covered  with  au  adhesive  mixture.  Hiisner^*  uses  buckskin  strips 
which  he  causes  to  adhere  to  the  skin  by  means  of  a  mixture  of  Venetian 
shellac  in  absolute  alcohol  (1-4) .  These  strips  will  sustain  very  heavy 
weights  and  are  easily  removed  without  pain  by  the  use  of  alcohol. 
The  adhesive  mixture  may  be  sprayed  upon  the  desired  portion  of  the 
limb  by  means  of  an  atomizer ;  the  strips  placed  in  situ  and  surrounded 
by  the  ordinary  roller  bandage. 

Instead  of  the  wooden  spreader,  Bardenheuer^^  uses  a  wide  buckle 
to  hold  the  strips  together.  Helferich^*  uses  two  iron  rings  sewed  into 
the  ends  of  the  strips ;  these  may  be  approximated  or  spread  apart  by 
hooks.  The  weights  are  suspended  by  a  heavy  wire  which  passes  over 
a  roller  pulley  fastened  to  the  end  of  the  bed.  The  weights  may  con- 
sist of  sandbags,  bricks,  flat- 
irons,  etc.  The  limb  must  be 
kept  from  rubbing  on  the  bed. 
Pillows  or  rolls  of  pasteboard 
covered  with  padding  may  be 
used.  The  knee  especially 
should  be  taken  care  of  in 
this  connection.  The  foot 
may  be  protected  by  a  sliding 
foot  rest  (p.  739).  The  proper 
amount  of  weight  is  con- 
trolled by  frequent  measure- 
ments and  by  the  use  of  the 
Rontgenogram.  At  first  about 
20  to  25  kilo  of  weight  may  be  applied.  Fig.  294  shows  the  Barden- 
heuer  extension  apparatus  in  sitic.  Longitudinal  traction  is  accom- 
plished by  the  strips  (a)  which  are  united  by  a  buckle;  to  this  the 
wire  and  weight  are  attached.  The  limb  is  suspended  by  transverse 
upward  traction  upon  the  leg  and  by  traction  upon  the  foot  in  the 
same  direction,  by  which  pointing  of  the  foot  is  obviated.  A  pillow 
is  placed  beneath  the  knee.  The  leg  and  the  thigh  are  kept  from 
rotating  outward  by  transverse  inversion  traction. 

Figure  295  shows  how  outward  rotation  of  the  limb  may  be  con- 
trolled, the  transverse  band  passing  through  a  slit  in  the  longitudinal 
one.  Also  a  simple  method  of  making  downward  traction  upon  a 
certain  portion  of  the  limb,  the  strip  running  over  the  leg  and  passing 
beneath  a  wooden  frame  lying  under  it.     The  illustration  also  shows 


Fig.  295. —  Accessory  Apparatus  Used  in 
Connection  with  Bardenheuer 's  Exten- 
sion Apparatus. 


742     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

liow  transverse  traction  upward  may  be  made,  and  a  means  of  obviat- 
ing backward  luxation  of  the  foot. 

Extension  with  heavy  weights  demands  the  use  of  couiiterextenslon 
with  the  view  of  keeping  the  patient  from  being  dragged  to  the  end 
of  the  bed,  which  would  cause  the  extension  to  become  ineffectual. 
Counterextension  is  effected  by  elevating  the  foot  of  the  bed  (25  to 
40  cm.)  so  that  the  patient's  hody  acts  as  a  counterweight;   or,  which 


Fig.  296. —  Method  of  Treating  High  Fracture  of  the 
Femur  with  Thomas  Splint  and  B7u:.kan  Frame  Sus- 
pension (Blake). 


is  less  uncomfortable,  a  padded  girdle  may  be  passed  around  the  body 
and  fastened  to  the  head  of  the  bed. 

Lateral  traction  is  accomplished  by  the  means  indicated  in  Figs. 
294-295.  In  this  way  the  correction  may  be  made  at  any  desired 
portion  of  the  limb  without  danger  of  the  occurrence  of  malposition. 
The  cords  or  wires  attached  to  the  transverse  strips  may  be  carried 
over  roller  pulleys  attached  to  boards  fastened  to  the  side  of  the  bed. 


SPECIAL  FRACTURES 


743 


For  backward  traction,  Bardenheuer^^  uses  a  small  frame  beneath 
which,  the  transverse  strips  are  passed.  Traction  and  suspension  are 
also  satisfactorily  attained  by  means  of  the  Balkan  frame  (p.  657). 
Blake^^  found  the  method  especially  useful  in  gunshot  wounds  involv- 
ing the  bone  in  this  situation.  The  limb  is  .suspended  in  a  Thomas 
splint  and  traction  made  with  a  sling,  or,  in  uncomplicated  cases, 

adhesive  strips  may 
be  used.  Figure  296 
gives  an  adequate 
notion  of  the  ar- 
rangement of  the 
apparatus.  It  will 
be  seen  that  all 
of  what  is  accom- 
plished by  means  of 
the  plaster  strips  in 
connection  with  the 
Bardenheuer  method 
is  attained  by  the 
weights  as  shown. 

The  use  of  the 
gypsum  dressing  in 
cases  of  fracture  of 
the  neck  of  the 
femur  has  its  advo- 
cates. Of  these, 
AYhi'man^^  would 
seem  to  offer  a 
method  of  signal 
sers'iee.  The  patient 
is  placed  on  the 
Hawley  table,  the 
limb  is  abducted, 
and  it,  together  with  the  pelvis,  is  encased  in  a  circular  gypsum  dress- 
ing by  means  of  a  hip  spica.  The  method  is  especially  indicated  in 
cases  of  lateral  fracture  of  the  neck  of  the  femur  in  healthy  (not 
elderly)  persons. 

The  ambulatory  treatment  of  this  class  of  cases  is  taken  up   in 
connection  with  fractures  of  the  shaft  of  the  femur  (p.  749). 
The  operative  methods  of  relief,  such  as  nailing  or  fixation  with 


Fig.  297. —  Immobilizatiox  of  Fracture  of  the  Neck 
OF  THE  Femur  (Whitman). 

The  gypsum  is  applied  with  the  limb  in  complete  ab- 
duction, complete  extension  and  slight  inward  rotation. 


744    INJUKIES  TO  SOFT  PAKTS,  BONES  AND  JOINTS 

drills,  plates,  etc.  (p.  792),  are  indicated  only  in  special  cases.  Imme- 
diate excision  of  the  head  of  the  bone  in  cases  of  medial  (intracap- 
sular) fractures  has  been  recommended.  It-  must  be  given  serious 
consideration  before  execution. 

The  e7id  results  are  often  anything  but  brilliant.  In  elderly  per- 
sons one  should  be  content  with  the  ability  to  get  about  with  the  help 
of  a  cane.  In  young  people  the  results  are  likely  to  be  good.  This 
is  only  accomplished,  however,  by  the  expenditure  of  much  effort  and 
assiduous  attention  to  detail  in  meeting  the  indications. 

Epiphyseal  Separation  at  the  Upper  End  of  the  Femur. —  This 
is  a  rare  injury  and  is  seen  only  in  young  persons.  Its  rarity  is  in 
contradistinction  to  the  upper  end  of  the  humerus,  where  the  separa- 
tion frequently  occurs.  The  explanation  lies  in  the  fact  that 
in  the  femur  the  epiphysis  is  small,  does  not  give  attachment 
to  the  capsule  and  is  entirely  intra-articular.  The  causation  and 
symptoms  are  similar  to  those  of  medial  fracture  of  the  neck  of  the 
femur.  The  treatment  is  the  same  as  in  the  latter  class  of  cases. 
The  separation  may  be  responsible  for  the  condition  known  as  coxa 
vara. 

Fractures  of  the  Femur  in  the  Region  of  the  Trochanter. — 
These  are  usually  extensions  of  lateral  fractures  of  the  neck  downward 
or  of  infratrochantic  fractures  upward.  They  possess  no  clinical 
significance  beyond  the  problem  taken  up  in  connection  with  lateral 
fractures  of  the  neck  of  the  femur. 

Isolated  Fracture  of  the  Trochanter  Major. —  Such  a  fracture 
is  of  practical  import-ance.  The  lesion  is  rare  and  is  produced  hy 
direct  violence.  The  fragment  is  luxated  upward  by  the  traction  of 
the  glutei  muscles,  and  is  thus  separated  to  a  considerable  extent  from 
its  normal  position.  Reposition  is  assisted  by  abducting  the  limb. 
The  trochanter  is  best  nailed  in  place  and  the  limb  immobilized  in  the 
abducted  position. 

Fracture  of  the  Trochanter  Minor. —  This  condition,  since  the 
advent  of  Eontgenography,  has  been  found  to  be  less  rare  than  it  was 
believed  to  be.  It  coexists  in  connection  with  severe  fractures  of  the 
upper  end  of  the  femur  and  is  generally  regarded  as  an  avulsion 
fracture.  The  displacement  is  caused  by  the  traction  of  the  iliopsoas 
muscle  and  is  likely  to  be  considerable  in  extent.  It  could  be  nailed 
in  place,  but  this  is  rarely  necessary. 

Fractures  of  the  Shaft  of  the  Femur  Below  the  Trochanters. — 
Fractures  of  the  shaft  present  certain  important  peculiarities. 


SPECIAL  FRACTUKES 


745 


Fractures  in  this  situation  caused  by  direct  violence  (blow,  fall)  are 
tlie  result  of  bending  or  of  angulation  and  are  usually  transverse. 
AVhen  indirect  violence  is  the  provocative  force  the  lesion  is  a  torsion 
fracture;  this  is  usually  spiral  and  is  characterized  by  a  long  fracture 
line.  The  torsion  fracture  is  often  produced  by  twisting  the  bod}^  or 
by  a  fall  upon  the  foot.     As  a  rule,  there  is  considerable  displacement. 

Beyond  the  symptoms  common  to  all  fractures,  which  are  com- 
pletely present,  the  lesion  is  characterized  by  an  almost  right  angled 
flexion  of  the  upper  fragment,  the  result  of  the  action  of  the  iliopsoas 


Fig.  298. —  Flexion  and  Abduction  of  the  Thigh  in  the  Treatment  of  Sub- 
trochanteric Fracture  of  the  Femur. 

The  gypsum  is  applied  after  reposition  has  been  accomplished  with  the  Hawley 
table. 


and  glutei  muscles.  In  manipulating  the  limb  (especially  in  rotation) 
the  trochanter  remains  quiescent. 

Reposition  is  not  easy;  the  patient  should  be  narcotized.  After 
reduction,  the  extension  apparatus  previously  described  (p.  739)  is 
applied  with  the  thigh  flexed. 

The  abduction  and  flexion  of  the  upper  fragment  in  this  class  of 
cases  render  maintenance  of  reposition  by  external  means  alone  quite 
impracticable.  For  the  purpose,  the  open  methods  of  relief  (p.  808) 
are  generally  employed  (Davidson  and  Smith^^).  However,  it  is 
equally  true  that  the  open  method  of  fixation   (plates,  inlays,  etc.) 


746     INJURIES  TO  SOFT  PARTS,  BONE»  AND  JOINTS 


^■» 


D  ^ 

YiG,  2&9.— Various  Fractures  of  the  Femur. 
A,  Normal  femur;  B,  C,  D,  E,  healing  in  malposition;  E,  is  typical 
of  fracture  in  this  location. 


SPECIAL  FRACTURES 


747 


must  be  supplemented  by  placing  the  limb  in  a  position  which  assists 
in  maintaining  reposition.  For  the  purpose,  the  extension  apparatus 
described  (p.  739)  is  a  useful  measure,  though  not  as  certain  as  the 
gypsum  dressing  applied  under  the  conditions  shown  in  Fig.  298. 

Fractures  of  the  Shaft  Near  the  Middle. —  Fractures  of  the  dia- 
physis  of  the  femur  at  its  middle  (Figs.  299-300)  are  common.  A 
large  proportion  are  caused  by  torsion  (oblique  and  longitudinal  frac- 
tures), though  a  certain  number  are  lending  fractures  caused  by 
direct  violence  (such  as  the  passage  of  a  wheel  over  the  thigh). 

They  also  occur  very  frequently  in  children,  in  whom  the  periosteum 

is  often  preserved,  so  that  luxation  of  the 
fragments  may  be  inconsiderable.  In  the 
adult  the  malposition  is  likely  to  be  great ; 
the  line  of  the  fracture  is  usually  oblique. 
Ahnormal  mohility  is  readily  established 
and  crepitus  is  easih'  elicited.  In  this  loca- 
tion the  absence  of  the  latter  is  especially 
indicative  of  the  interposition  of  soft  parts 
and  must  be  demonstrated  before  the 
attainment  of  reposition  is  assured.  Short- 
ening is  always  present  and  may  be  con- 
siderable. 

Fractures  of  the  middle  of  the  femur  are 
often  characterized  by  a  typical  displace- 
ment which,  unfortunately,  is  often  main- 
tained after  union  has  taken  place  and  will 
demand  subsequent  operative  relief  for 
correction  of  the  deformity.  The  luxation 
shows  forward  outward  angular  protrusion 
That  is,  the  upper  fragment  is  erected  by 
the  action  of  the  muscles  attached  to  the  trochanters ;  the  lower  one  is 
drawn  upward  and  is  adducted.  At  times,  the  lower  fragment  is 
simply  tilted  backward.  The  formation  of  a  pseudo-arthrosis  is  not 
infrequent. 

The  treatmejit  of  fractures  of  the  femoral  diaphj'sis,  since  the  advent 
of  the  extension  apparatus,  is  much  simplified.  '^ However,  it  is  erro- 
neous to  assume  that  this  treatment  is  easily  carried  out.  The  dress- 
ing must  be  correctly  applied,  it  must  not  make  pressure,  and  must  be 
strong  enough  to  make  the  use  of  from  twenty  to  twenty-five  pounds 
of  extension  possible"   (Helferich").     The  reader  is  reminded  that 


Fie.  300.— Typical  Luxa- 
tion IN  Fracture  of 
THE  Middle  op  the 
Femur. 

The  upper  fragment  is 
erected  by  the  ' '  pull ' '  of 
the  iliopsoas  muscle. 

at  the  site  of  the  fracture. 


748     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


for  the  purpose  he  must  use  sailcloth  plaster  strips  (p.  7-il),  not  the 
ordinary  adhesive  plaster.  To  avoid  friction  of  the  leg  on  the  bed  the 
sliding  footboard  (Fig.  302),  which  also  permits  of  the  proper  postur- 
ing of  the  foot  (slightly  inverted)  must 
be  employed.  Counter  extension  is  best 
made  by  elevating  the  bed,  and  a  block 
of  wood  should  be  placed  in  the  bed, 
against  which  the  sound  foot  rests. 

With  the  injured  person  thus  pos- 
tured, the  position  of  the  fragments  is 
controlled.  As  the  thickness  of  the 
muscles  of  the  thigh  makes  direct  pal- 
pation of  the  fragments  impossible,  the 
effect  of  the  treatment  is  standardized 
by  measurements  of  the  length  of  the 
limb  as  compared  to  the  opposite  one. 
For  the  purpose,  the  horizontal  axis  of 
the  pelvis,  a  line  between  the  two 
anterior  spines,  must  be  determined. 
Thus  the  degree  of  abduction  of  the 
injured  limb  is  easily  determined  and 
the  sound  one  is  postured  accordingly 
(Fig.  303).  When  this  is  done  the 
longitudinal  measurements  may  be 
taken  and  a  comparison  made. 

In  this  class  of  cases  the  use  of  trac- 
tion and  suspension  in  connection  with 
the  Balkan  frame  meets  the  indications 
in  a  number  of  instances.  The  accom- 
panying illustration  (Fig.  304)  shows 
the  limb  resting  on  a  Hodgen's  splint. 
Traction  is  made  by  a  Besley  tongs. 
Abduction  is  obtained  b}'  placing  the 
pulley  for  the  traction  cord  on  an  out- 
rider, and  outward  rotation  by  tilting 
the  splint. 

In  children,  vertical  extension  is  a  long  tried  and  very  effectual 
method  of  treatment  (Fig.  305)  ;  the  posture  is  maintained  for  three 
weeks.  Theoretically,  it  would  seem  as  though  the  anemia  caused  by 
the  position  would  prevent  callus  formation ;    practically^,  this  is  not 


Fig.  301. — ^  Rontgenogram  of 
Spiral  (Torsion)  Fracture 
OF  DiAPiiYSis  OF  Femur  in 
A  Young  Person  (Helfe- 
rich). 


SPECIAL  FRACTURES 


749 


the   case.     It  is  astonishing  to   see   how  happy   the  children   thus 
"trussed  up"  really  are. 

In  the  neivhj  horn  and  in  very  small  children  the  thigh  is  flexed  on 
the  abdomen  and  held  there  by  means  of  a  broad  strip  of  adhesive 


Fig.   302. —  ExTExsiox   "Sled,"  Easily  Put   Together  and  Readily 

Improvised. 


Fig.  303. —  Proper  Method  of  ^Measurement  in  Fractures 
OF  THE  Femur. 

The  tilt  of  the  pelvis  is  outlined  by  the  means  shown,  and 
the  two  legs  are  symmetrically  postured. 


plaster.  Or,  the  thigh  is  flexed  to  right  angles  at  the  hip  and  knee 
and  the  entire  limb  together  with  the  pelvis  arc  immobilized  in 
gypsum. 

The  principle  of  the  amhidaiory  treatment  is  based  upon  using  the 


750    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

tuber  ischii  as  a  support,  so  that  the  pelvis  rests  upon  it  and  the 
injured  limb  is  free ;  the  foot  may  be  in  contact  with  the  distal  portion 
of  the  apparatus,  provided  this  is  longer  than  the  leg.  The  simplest 
apparatus  of  this  sort  is  the  one  originated  by  H.  0.  Thomas^^  of 
Liverpool  (Fig.  306).  It  is  widely  used  at  the  end  of  three  or  four 
weeks  of  extension  treatment  and  gives  excellent  results. 


Fig.  304. —  Method  of  Suspension  and  Traction  of  Fractures  of 

THE   DiAPHYSIS    OF   THE   FeMUR. 

Traction  is  made  with  the  Besley  Tongs   (Blake). 

Gypsum  dressings  may  also  be  used  for  the  purpose.  The  gypsum 
is  applied  directly  to  the  (anointed)  skin.  The  foot,  leg  and  region 
of  the  knee  are  inclosed  in  gypsum  and  a  broad  ring  of  the  same 
encircles  the  buttocks  (Fig.  307).  The  intermediate  portion  of  the 
thigh  is  inclosed  while  traction  is  made  on  the  foot  (Fig.  308). 


SPECIAL  FRACTURES 


751 


There  is  no  doubt  that  a  certain  number  of  fractures  of  the  femur 
may  be  successfully  treated  by  the  early  application  of  ambulatory 
apparatus.  However,  the  writer  does  not  regard  this  as  indicated, 
except  in  cases  in  which  there  is  a  distinct  contra-indication  to  the 
confinement  coincident  to  the  use  of  the  extension  apparatus  as 
described.     The  latter  need  not  be  employed  for  more  than  three  or 

four  wrecks.  The  application  of  am- 
bulatory apparatus  requires  especial 
technic  and  the  use  of  material  not  at 
the  disposition  of  most  practitioners. 
In  fractures  above  the  middle  of  the 
femur,  the  flexion  of  the  upper  frag- 
ment renders  the  application  of  an 
ambulatory  apparatus  impracticable, 
as  fixation  in  reposition  is  impossible 
under  these  circumstances. 

Wheii  a  fracture  unites  in  a  faulty 
position  the  fragments  must  be  sep- 
arated (osteoclasis  and  osteotomy) 
and  the  extension  treatment  carefully 
carried  out.  In  these  cases  the  nail 
extension  (p.  752)  and  similar 
methods  of  direct  extension  may  be 
used.  Pseudo-arthrosis  is  treated  by 
operative  methods  of  relief  (p.  833). 
Fractures  of  the  Lower  Exd  op 
THE  Femur  (Fig.  309). —  Fractures 
of  the  lower  end  may  be  divided  into : 

1.  Fracture  of  the  femur  alove 
the  condyles,  i.  e.,  siipracandyloid 
fractures,  usually  transverse. 

2.  True  epiphyseal  separations  in 
young  persons. 

3.  Oblique  and  T  fractures  of  the  condyles. 

4.  Avulsion  fractures  of  the  joint  surfaces. 
SuPRACONDYLOiD    FRACTURES. —  Supracondyloid    fractures    of    the 

femur  are  usually  transverse,  though,  at  times,  an  oblique  fracture 
with  tapered  fragments  occurs,  and,  occasionally,  a  torsion  fracture 
is  longitudinal. 

In  the  transverse  fracture  the  lower  fragment  is  tilted  backward 


Fig.  305. —  Vertical  Suspension 
IN  Fracture  of  the  Femur  in 
Children. 

The  traction  also  abducts  the 
limb,  as  may  be  seen  by  the  way 
the  pelvis  is  tilted. 


752     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

by  the  traction  of  the  muscles  of  the  calf  of  the  leg ;  the  overriding  is 
likely  to  be  considerable  in  extent  (Fig.  309)  and  is  caused  by  the 
action  of  the  muscles  of  the  thigh,  which  displace  the  lower  fragment 
upward  and  shorten  the  limb. 

Inspection  reveals  the  shortening  and  the  swelling ;  movements  are 
very  painful.  Palpation  elicits  false  motion.  Crepitus  is  manifested 
when  the  fragments  are  in  contact  with  each  other.  The  upper  end 
of  the  lower  fragment  may  be  felt  behind  and  the  lower  end  of  the 
upper  fragment  in  front.  For  the  diagnosis  and  for  reposition 
narcosis  is  desirable. 


Fig.  306. —  The  Thomas  Splint, 

A,  The  weight  of  the  body  is  carried  on  the  tuber  isehii.  The  leg  may 
be  attached  to  the  footpiece  by  means  of  leather  straps  and  buckles,  and 
fastened  to  the  side  bars  by  bandages. 

B,  shows  the  splint  arranged    for    double    inclined   plane    (Blake). 

The  treatment  consists  in  the  use  of  permanent  extension.  As  not 
a  few  cases  show  a  tendency  toward  recurrence,  extension  with  the 
knee  in  the  flexed  position  is  often  necessary. 

For  the  purpose,  apparatus  constructed  on  the  principle  shown  in 
Figs.  310-311  may  be  used  with  advantage.  The  classic  double  in- 
clined plane  also  accomplishes  the  purpose  in  some  instanjees,  though, 
Zuppinger's  apparatus  is  more  likeh^  to  be  effective.  In  not  a  few 
cases,  it  becomes  necessary  to  resort  to  direct  extension.  In  just  this 
class  of  cases,  nail  extension  often  attains  the  desired  end  and  is  for 
this  reason  described  in  this  connection. 

In  nail  extension  in  fracture  of  the  lower  end  of  the  femur  (Fig. 


SPECIAL  FRACTURES 


753 


312),  two  nails  or  pegs  are  driven  into  the  epiphyses  of  the  peripheral 
fragments  and  traction  is  made  directly  upon  the  latter.  This 
method  is  used  in  the  class  of  cases  stated  and  is  often  employed  after 
osteoclasis  or  osteotomy  for  union  of  the  bone  in  faulty  position. 
Weight  up  to  forty  pounds  is  well  borne.  The  limb  is  suspended  as 
shown  in  connection  with  the  Balkan  frame  (Fig.  304). 

Traumatic  Separation  of  the  Lower  Epiphysis  of  the  Femur. — 
This  is  not  rare.     As  the  epiphysis  is  of  small  dimensions  compared 


Fig.  307. —  Application  of  Gypsum  Dressing  in  the  Ambulatory  Treatment 
OF  Fracture  of  the  Femur. 

The  foot,  knee,  and  lower  portion  of  the  thigh  are  enclosed;  the  "buttock  ring" 
is  also  applied.  The  patient  is  placed  on  a  pelvic  rest  (the  Hawley  table  may  be 
used  for  the  purpose).  The  assistant  makes  strong  traction  while  the  intermediate 
portion  of  the  apparatus  is  applied  (Fig.  308). 


to  the  diaphysis,  the  provocative  force  must  he  great.  As  a  rule,  the 
lesion  is  not  attended  with  much  displacement  and  the  periosteal  con- 
nections are  often  preserved.  The  luxation  is  mostly  that  of  the 
tj'pical  transverse  supracondyloid  fracture  (Fig.  309),  though  occa- 
sionally the  reverse  displacement  occurs.  This  is  dependent  upon  the 
direction  of  the  causative  trauma.  The  knee  joint  is  almost  always 
involved  (hematoma  articularis). 

Examination  reveals  thickening  and  pressure  pain  at  the  epiphyseal 
line.  At  times,  the  deformity  is  palpable  and  soft  crepitus  and 
abnormal  mobility  (by  abduction  and  adduction  of  the  leg)  mav  be 


754    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


elicited.     The  diagnosis   is   not    easy   but    is   readily   made    in   the 
Rontgenographic  picture. 

Reposition  is  made  under  narcosis.     Fixation  as  in  supracondyloid 
fracture.     Operative  reposition  and  fixation    (p.  808)    (wlieu  other 
means  fail)  must  not  be  too  long  post- 
poned,   as    malposition    will    seriously 
affect  motion  in  the  knee  joint. 

Oblique  and  T  Fractures  of  the 
Condyles. —  Such  fractures  are  both 
intra-  and  extra-articular.  The  outer 
or  the  inner  condyle  may  be  broken  off 
or  a  T  fracture  may  be  present.  The 
diagnosis  is  based  on  the  broadening  of 
the  region  of  the  condj'des,  pain  on 
pressure,  lateral  mobility  at  the  knee, 
crepitus  and  palpation  at  the  point  of 
the  fragment,  and  the  presence  of  a 
bloody  effusion  in  the  joint.  The 
treatment  consists  in  fixation  in  an  ex- 
tension dressing,  compression  over  the 
joint,  aspiration  of  the  effused  blood, 
early  passive  motion  and  massage  (me- 
chanicotherapy). 

Avulsion  of  Thin  Portions  op 
Bone. —  A^a^lsions  of  portions  of  bone 
at  the  insertion  of  the  lateral  ligaments 
and  of  portions  of  the  articular  carti- 
lages are  taken  up  later. 

Fractures  of  the  Patella  (1.4  per  cent 
of  all  fractures). —  Fractures  of  the 
patella  are  caused  by  direct  violence, 
such  as  a  fall  or  a  blow  upon  the  knee. 
Fractures  of  this  sort  are  likely  to  be 
stellate  or  multiple;  as  a  rule,  the  frag- 
ments are  not  widely  separated. 

Indirect  fractures  are  caused  by 
patella  is  fixed  by  the  patellar  ligament,  ar  sudden  forceful  contraction 
of  the  quadriceps  muscles  exercises  a  severe  strain  upon  the  patella 
(which  is  embedded  in  the  aponeurosis  of  the  muscle)  and  an  avulsion 
fracture  occurs.     The  fracture  is  usually  transverse  and  is  most  often 


Fig.  308.  —  Completed  Ambula- 
tory Gypsum  Dressing  for 
Fractures  of  the  Middle  and 
Lower  Portion  of  the  Femur. 

muscular    contraction.      The 


SPECIAL  FRACTURES 


755 


located  either  at  the  middle  of  the  patella  or  somewhat  lower  down 
where  the  bone  begins  to  taper.  It  must  be  remembered  that  patellae 
vary  considerably  in  size  in  different  individuals;  this  is  important 
in  the  examination. 

The  aponeurotic  hands  located  on  either  side  of  the  patella  are  of 
great  import ;  in  a  general  way  it  may  be  said  that  these  are  more 
often  torn  in  indirect  fractures  than  in  direct,  although  they  may  also 


Fig.  309. —  A,  ARTrPl;ciAL- 
LY  Produced  Supracon- 
DTLOiD  Fracture  of  the 
Femur. 


B,  Oblique  Fracture  of  the  Lower  End  of  the 
Femur  (Fracture  of  Internal  Condyle). 

C,  Traumatic  Epiphyseal  Separation  at  the 
Lower  End  of  the  Femur. 


be  torn  in  the  latter  instance,  especially  when  the  provocative  force  is 
received  while  the  knee  is  flexed.  The  extent  to  which  these  bands 
are  torn  determines  the  degree  of  separation  of  the  fragments  of  the 
fractured  patella. 

The  symptoms  are  clearly  defined  when  the  fracture  is  transverse 
and  located  near  the  middle  of  the  patella  and  attended  with  appre- 
ciable separation  of  fragments.  As  the  patella  is  included  in  the 
joint  capsule  the  fracture  is  an  intra-articular  lesion;   consequently, 


756     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


there  is  always  more  or  less  effusion  of  blood  into  the  joint ;  usually 
this  is  extensive.  In  fresh  eases  the  fragments  may  be  approximated 
so  that  crepitus  is  elicited.     When  only  a  small  rim  of  the  patella  is 

avulsed  or  when  the  periosteum 
as  a  whole  is  preserved,  the 
diagnosis  is  not  as  clear;  how- 
ever, careful  palpation  will 
alwa^^s  reveal  displacement  of 
the  fragments. 

The  prognosis  depends  upon 
the  character  and  degree  of  the 
injurij  (transverse,  stellate,  in- 
jury to  the  ligaments,  etc.). 
The  lesion  is  followed  by  les- 
sening of  the  stability  of  the 
knee  joint  and  by  some  inter- 
ference ivith  mobility.  In  per- 
sons who  lead  sedentary  lives 
this  may  not  be  important ; 
however,  in  laborers  the  lower- 
ing of  their  earning  capacity 
is  considerable.  Even  though 
motion,  and,  indeed,  the  ability 
to  extend  the  leg  may  seem 
to  be  normal,  the  limb  is  left 


Fig.  310. —  Appar.\tus  for  Fracture  of 
THE  Lower  Half  of  the  Femur. 

The  upper,  or  femoral,  gutter  (o)  and 
the  lower  splint  (u)  meet  at  the  pos- 
terior fold  of  the  kne?:  this  point  moves 
away  from  the  hip  when  the  foot  end  is 
lowered,  i.e.,  by  the  weight  of  the  leg. 
When  the  foot  is  fastened  to  the  foot- 
board (F)  the  femur  is  lengthened.  The 
brace  (s)  is  fixed  at  the  pegs  (d),  which 
permits  of  adjustment  on  the  bedplate 
(G)   (Helferich). 


Fig.  311. —  Apparatus  Shown  in  Fig.  310  m  Use. 

The  strips  of  plaster  affixed  to  the  leg  hold  the  foot  in  con- 
tact with  tlie  padded  footboard.  The  bedplate  reaches  to  the 
buttock.  The  leg  is  bandaged  to  the  leg  splint ;  when  this  is 
lowered,  automatic  extension  occurs.  The  traction  loops 
carried  over  the  pegs  in  the  footpiece  are  so  adjusted  as  to 
produce  appreciable  traction,  without  causing  pain  (Hel- 
ferich). 


SPECIAL  FRACTURES 


757 


enfeebled  and  locomotion  on  uneven  ground  is  uncertain,  so  that 
the  person  is  likely  to  fall  or  contract  other  injuries  (refracture).  Of 
283  cases,  223  were  treated  without  suture,  32  of  which  healed  by 
bony  union  (14  per  cent).     Sixty  were  sutured  and,  of  these,  45  (75 


Fig.  312. —  Schematic 
Represextatiox  of 
Nail  Extension  Ap- 
plied TO  THE  Lower 
End  of  the  Femur 
(Steimann). 


Fig.  313. —  A,  Fractltre  of  the  Lower  End 
of  the  Femur  Healed  in  Malposition.  B, 
The  Same  Fracture  After  Osteoclasis  and 
Treatment  With  Nail  Extension. 


per  cent)  healed  by  bony  union.     In  none  of  the  cases  was  the  limb 
as  strong  as  the  uninjured  one  (Helferieh-*). 

Trcatmenf. —  "While  in  no  other  class  of  fracture  is  wide  separation 
of  the  fragments  as  frequently  followed  by  healing  and  return  of 


758     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


function,  it  is  also  true  that  in  no  other  class  of  fractures  is  healing 
without  malposition  so  often  followed  by  impairment  of  function. 
This  is  ascribed  to  the  peculiar  influence  of  the  quadriceps  muscle. 
This  muscle  often  exhibits  a  marked  degree  of  atrophy  which  is  due 
to  disuse  and,  more  especially,  is  the  result  of  reflex  influences  through 
the  trophic  center  in  the  spinal  cord.  As  this  atrophy  may  not  appear 
until  after  the  primary  surgical  treatment  it  must  be  taken  into 
account  in  the  prognosis.     With  the  view  of  counteracting  the  influ- 


FiG.  314. —  A,  Preparation  of  a  Typical  Transverse  Fracture  op  the  Patella 
WITH  Extensive  Tearing  of  the  Aponeurotic  Tissue. 

Wide  separation  of  the  fragments.     Shreds  of  aponeurosis  overhang  the  ends 
of  the  fragmeijts. 

B,  Preparation  of  a  Transverse  Fracture  of  the  Patella  without  Exten- 
sive Tearing  of  the  Aponeurosis. 

Moderate  separation  of  the  fragments  despite  flexion  of  the  knee. 

ence  of  disuse  a  number  of  cases  have  been  treated  by  simply  placing 
the  limb,  with  the  knee  extended  and  the  hip  flexed,  upon  a  posterior 
splint.  The  fragments  are  manually  approximated  and  the  thigh 
massaged  several  times  daily.  Although,  the  method  possesses  merit, 
there  does  not  seem  to  be  any  reason  why  the  fragments  should  not  be 
held  in  as  close  apposition  as  possible  at  the  same  time  as  massage, 
etc.,  is  being  carried  out. 

There  are  probably  several  causes  for  the  unfavorable  results  follow- 
ing' fracture  of  the  patella.     The  drag  of  the  quadriceps  muscle  and 


SPECIAL  FRACTUKES 


759 


the  consequent  diastasis  of  the  fragments  is  an  important  factor;  so 
is  the  atrophy  of  this  muscle  (already  alluded  to)  which,  in  not  a  few 
cases,  is  peculiarly  great  compared  to  the  moderate  extent  of  the  bone 
injur}'.  The  effusion  of  hlood  into  the  joint,  which  crowds  the  frag- 
ments apart,  is  also  regarded  as  a  contributory  factor.  In  addition  to 
this,  the  patella  is  poorly  supplied  with  hlood  and  is  believed  to  possess 
only  a  meager  tendency  to  callus  production.     The  latter  is  probably 


.4"^ 


Fig.  315. —  A,  Prepakation  of  a  Healed  Multiple  Fracture  of 
THE  Patella;  B,  Fractured  Patella  with  Fibrous  Union". 


not  true,  as  the  bone  is  covered  with  a  thick  layer  of  cartilage  on  its 
articular  side  and  is  encased  in  fibrous  tissues  on  the  others. 

The  interposition  of  the  stretched  and  lacerated  fibers  of  the  apo- 
neurosis of  the  fragments  presents  a  factor  almost  certain  to  lead  to 
ligamentous  union,  even  though  fixation  in  apposition  is  attained. 

Finally,  the  ultimate  outcome  is  not  a  little  influenced  by  a  peculiar 
atrophy  of  the  joint  that  attends  this  injury  (which  is  not  susceptible 


760     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

of  elucidation),  and  by  the  fact  that  the  patella  often  adheres  to  the 
anterior  surface  of  the  condyles. 

The  treatment  is  directed  toward  obviating  the  natural  obstacles. 
In  order  to  relax  the  quadriceps  muscle  the  limb  is  fully  extended  at 
the  knee  and  flexed  at  the  hip  joint.  The  knee  is  fixed  with  a  posterior 
splint  (gypsum  or  felt).  The  fragments  are  manually  apposed  and 
are  then  fixed  w^ith  plaster  strips  arranged  in  the  form  of  a  sling,  the 
loops  of  which  make  downward  pressure  upon  the  upper  fragments 
and  cross  over  the  posterior  splint.  Yoluminous  effusion  of  blood  is 
removed  by  aspiration;  for  the  purpose,  the  needle  should  be  of 
ample  lumen.  The  quadriceps  muscle  is  massaged  twice  daily,  in  the 
downward  direction  with  the  view  of  enhancing  reposition.  The  use 
of  the  galvanic  current  is  not  objectionable,  the  application  of  iodin  is. 

A  gypsum  immoMlizmg  'dressing  may  be  used  when  there  is  not 
much  separation  of  the  fragments.  At  the  end  of  fourteen  days  this 
is  cut  down,  massage  is  begun,  and  the  posterior  portion  of  the 
apparatus  used  as  a  removable  splint. 

The  more  closely  the  fragments  are  apposed,  the  better  the  ultimate 
result.  As  healing  of  the  fragments  b}'  a  sort  of  primary  union  is 
desirable,  operative  measures  of  relief  may  be  employed  unless  there 
is  an  especial  contraindication. 

Additional  Intra- Articular  Injuries  of  the  Knee  Joint. —  Avulsion  of 
the  articular  cartilage  of  the  femur  (Fig.  316A)  is  a  common  injury. 
The  ends  of  the  bones  entering  into  the  formation  of  the  knee  joint  are 
not  arranged  as  a  pure  hinge  joint ;  with  the  knee  flexed,  moderate 
abduction,  adduction,  and  rotation  may  be  executed.  These  motions 
are  limited  by  the  crucial  ligaments  and  the  semilunar  cartilage. 
With  the  knee  flexed  the  action  of  compression  force,  combined  with 
lateral  displacement,  is  likely  to  avulse  a  portion  of  the  articular 
cartilage,  together  with  a  "sliver"  of  the  spongiosa  of  the  bone. 
The  cartilaginous  layer  of  the  fragment  possesses  a  sharp  border,  while 
the  spongiosa  tapers  more  or  less.  The  fragment  varies  from  that 
of  a  bean  to  an  almond  in  size.  The  avulsed  segment  may  be  entirely 
separated  (corpus  mobile,  joint  mouse,  p.  595)  or  ma}^  remain  attached 
to  the  bone  by  filaments  of  tissue  and  gradually,  as  the  result  of 
repeated  pressure  and  displacement,  become  separated  later  on 
(Volker^«). 

Injuries  of  the  semilunar  cartilages  (Fig.  316B)  consist  in  luxa- 
tions and  rupture,  and  may  exist  as  isolated  injuries  or  may  occur  as 
complications  of  other  lesions  of  the  knee  joint.     The  inner  cartilage 


SPECIAL  FRACTURES  761 

is  traumatized  twice  as  often  as  the  outer.  As  a  rule,  complete  sepa- 
ration from  the  joint  capsule  probably  does  not  occur.  lAvuIsion  of  its 
anterior  aspect  is  the  more  common.  Laceration  of  the  cartilage  in 
its  continuity  is  also  rare. 

The  lesion  is  caused  by  rotation  of  the  end  of  the  femur  with  the 
knee  flexed. 

The  symptoms  of  a  fresh  luxation  are  either  severe  or  slight,  accord- 
ing to  the  degree  of  the  causative  trauma.  Pain  in  the  region  of  the 
injured  cartilage  is  always  severe.  The  joint  is  held  in  moderate 
flexion  and  may  be  still  more  flexed,  but  cannot  be  extended.  Swell- 
ing, the  result  of  effusion,  varies  in  degree.  In  old  or  hahitual  luxa- 
tions the  pain  and  swelling  are  paroxysmal  and  are  provoked  by 
sudden  displacement  and  incarceration  of  the  cartilage. 

The  objective  examination  may  reveal  the  presence  of  a  movable, 
flat  body  at  the  joint  cleft ;  this  disappears  into  the  joint  when  it  is 
flexed  and  reappears  upon  extending  the  leg.  These  motions  are 
attended  by  an  appreciable  ''snap"  when  the  avulsed  cartilage  is 
permanently  displaced  into  the  interior  of  the  joint  cleft.  In  the 
presence  of  an  extensive  effusion,  the  cartilage  is  not  palpable. 

Treatment. —  In  fresh  cases  reposition  of  the  displaced  fragment 
should  be  attempted ;  this  is  not  always  possible.  Following  this, 
moderate  pressure  is  made  upon  the  joint.  Later,  the  joint  is  immo- 
hilized  for  six  weeks  in  gj^sum.  This  is  followed  by  the  use  of  a 
knee  cap  for  a  long  time.  In  old  or  hahitual  cases,  the  cartilage  may 
be  exposed  and  fixed  in  its  normal  position  by  means  of  buried  sutures. 
This  measure  is  more  desirable  than  removal  of  the  fragment.  How- 
ever, the  latter  procedure  is  not  followed  by  very  grave  loss  of  func- 
tion. In  not  a  few  cases,  disappearance  of  the  symptoms  has  followed 
the  protracted  use  of  an  apparatus  which  restricts  the  movements  of 
the  joint  to  flexion  and  extension. 

Avulsion  of  a  portion  of  the  interconehjloid  eminence  of  the  tibia 
by  a  crucial  ligament  is  attended  by  effusion  of  blood  into  the  joint 
and  tenderness  upon  pressure  upon  the  upper  end  of  the  tibia.  The 
diagnosis  is  made  b}'  means  of  the  Rontgenogram.  Operative  removal 
of  the  fragment  is  indicated. 

Isolated  Fractures  of  the  Upper  End  of  the  Tibia. —  Compression  frac- 
tures of  the  tibia  at  its  upper  end  (Fig.  316C-D)  are  caused  by  the 
sudden  impact  of  one  or  both  condyles  of  the  femur,  such  as  occurs  in 
a  fall  upon  the  foot  from  a  height. 

The  upper  articular  end  of  the  tibia  is  "caved  in"  and  the  frag- 


762     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

ments  are  impressed  into  tlie  spongiosa,  or  the  shaft  of  the  bone  is 
impacted  into  the  spongiosa  from  below. 

The  symptoms  are  essentially  those  of  an  intra-articular  injury. 
The  knee  joint  is,  at  first,  filled  with  blood,  later,  with  a  serous  effusion. 


Fig.  316. —  A,  Avulsed  Portion  of  Articular  Cartilage,  together  with  a 
Small  Portion  of  the  Bone  of  the  Internal  Condyle  of  the  Femur; 
B,  Eupture  of  the  Inner  Semilunar  Cartilage  in  the  Knee  Joint;  C-D, 
Preparation  of  a  Compression  Fracture  of  the  Upper  End  of  the  Tibia. 

The  articular  surface  is  seen  from  above  and  the  tibia  from  behind. 


Movements  of  the  joint  are  painful.  As  a  rule,  the  joint  "wobbles." 
The  upper  end  of  the  tibia  is  broadened  and  very  tender.  When  a 
fracture  involves  only  one  half  of  the  upper  end,  a  varus  or  valgus 
position  of  the  knee  joint  is  produced.  The  former  is  very  likely  to 
be  permanent.     The  injury  is  often  followed  by  arthritis  deformans. 


SPECIAL  FRACTURES 


763 


The  treatment  with  permanent  weight  extension  with  the  sliding 
footpiece  (p.  739)  is  of  value.  The  varus  or  valgus  position  must  be 
combated  by  lateral  "sling"  traction.  The  early  employment  of 
massage  and  passive  motion  is  imperative. 

Transverse  fracture  of  the  upper  end  of  the  tibia  is  infrequent.  It 
is  caused  by  direct   (such  as  a  hoof  kick)  and  b}-  indirect  violence. 


Fig.  317. —  A,  Prepakation  op  a  Healed  Fracture  of  Both  Bones 
OP  THE  Leg  with  Gross  Malpositiox;   B,  Preparation  op  a 
Healed    Fracture    at    the    Lower    Third    with    Moderate 
Depormity. 
The  fibula  is  fractured  at  its  upper  third;  no  malposition. 

C,  Control  Line  to  Determine  Correct  Position  of  the  Frag- 
ments in  Fracture  op  the  Leg. 
The  middle  of  the  patella  and  the  great  toe  are  on  a  line. 

The  fracture  line  is  often  oblique  and  usually  extends  into  the  knee 
joint ;   this  is  attended  with  the  etfusion  of  blood  into  the  latter. 

The  diagnosis  is  based  on  the  broadening  of  the  upper  segment  of 
the  bone,  the  tenderness  over  it,  the  abnormal  "wobble"  of  the  limb, 
and  the  findings  in  the  Rontgenogram. 


764     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  treatment  of  choice  is  that  of  permanent  extension,  adjusted 
with  the  site  of  fracture  exposed.  Like  all  cases  of  traumatic  bone 
lesions,  massage  and  passive  motion  should  begin  early.  These  are 
especially  easy  of  employment  when  the  apparatus  indicated  above 
is  used. 

Traumatic  epiphyseal  separation  at  the  upper  end  of  the  tibia  should 
be  borne  in  mind  in  connection  with  children.  The  diagnosis  can  only 
be  made  with  certainty  by  means  of  the  Rontgenogram.  As  the 
lesion  is  not  attended  with  a  tendency  to  recurrence  of  the  deformity, 
when  once  reduced,  immobilization  of  the  limb  by  means  of  gypsum 
answers  the  purpose. 

Avulsion  of  the  tuberosity  of  the  tibia  is  a  rare  injury;  it  is 
attended  with  considerable  upper  displacement  of  the  avulsed  segment 
of  bone.  This  is  due  to  the  ' '  drag ' '  of  the  quadriceps  extensor  muscle 
acting  through  the  patellar  ligament.  It  is  attended  with  inability  to 
actively  extend  the  leg.  The  fragment  is  clearl}^  palpable  beneath  the 
skin.  The  joint  is  usually  the  seat  of  a  bloody  exudate.  The  con- 
dition known  as  Schlatter's  disease  is  a  similar  lesion  occurring  in 
children.  The  "bill  shaped"  protrusion  of  the  epiphysis,  which  later 
develops  into  the  tubercle  of  the  tibia,  is  injured  and  this  is  usually 
followed  by  a  moderate  inflammatory  reaction. 

The  avulsed  tuberosity  is  best  held  in  position  by  flailing  (p.  796) 
and  the  limb  immobilized  in  extension. 

Isolated  Fractures  of  the  Capitulum  Fibulae. —  These  may  be  caused 
by  direct  (blow,  kick,  etc.)  or  by  indirect  violence,  such  as  a  sudden 
contraction  of  the  biceps  femoris  muscle  (avulsion  fracture).  The 
peroneal  nerve  is  likel}^  to  be  injured. 

Malposition  of  the  fragment  is  not  likely  to  be  marked.  In  case  it 
should,  nailing  or  suture  (p.  796)  is  indicated.  In  other  regards  the 
treatment  is  carried  out  on  general  principles. 

Fractures  of  the  Leg  at  Its  Middle. —  Fractur?  of  both  bones  in  the 
region  of  the  diaphysis  is  ver^^  common.  When  caused  by  direct 
violence  (''run  over"),  both  bones  are  usually  fractured  at  or 
near  the  same  level.  The  lesion  is  most  often  caused  b}^  indirect 
violence,  especially  by  torsion  with  the  foot  fixed.  In  this  way  the 
tibia  is  fractured  obliquely  and  the  fihula  is  secondarily  broken  by  the 
weight  of  the  body,  the  latter  being  a  bending  fracture.  Fractures  of 
this  sort  are  much  more  likely  to  be  oblique  than  transverse.  The 
point  of  the  upper  fragment  is  often  formed  like  the  mouthpiece  of  a 


SPECIAL  FRACTUKES 


765 


flute,  and,  in  not  a  few  instances,  perforates  the  skin  of  the  front  of 
the  leg. 

The  diagnosis  is  not  difficult;  it  is  based  on  the  abnormal  mohilitij 
and  luxation  of  the  fragments,  and  on  crepitus.  Rotation  of  the  lower 
fragment  is  recognized  by  observation  of  the  line  indicated  in  Fig. 
317C  and  by  following  the  crest  of  the  tibia  with  the  thumb.     The 

fracture  of  the  fibula  is 
often  not  recognized  until 
a  Rontgenogram  is  avail- 
able. 

The  examination  is  best 
carried  out  with  the  help 
of  an  assistant,  who  fixes 
the  knee  with  both  hands 
while  the  surgeon  places 
one  hand  over  the  site  of 
the  fracture  and  moves  the 
malleoli  in  various  direc- 
tions with  the  other. 

The  Rontgenogram  is 
especially  valuable  in  this 
class  of  cases  both  for  the 
diagnosis  and  for  the  con- 
trol of  the  treatment. 

The  treatment  is  begun 
with  as  exact  reposition  of 
the  deformitj'  as  possible, 
by  traction  on  the  foot  and 
counterextension     on     the 
thigh.      In    oblique    frac- 
tures,   in    which    the    de- 
FiG.  318.— RoxTGExoGRAM  OP  A  Traxsverse  fomiitv   is   overcome   with 
Fracture  of  the  Tibia  Caused  by  Direct   ,.->     ,'         jjv        ^  ^   u.       i 
Violence    (Harlem  Hospital  case).  difficulty,  additional  lateral 

traction  as  shown  in  Fig. 
319  may  be  advantageously  used.  Traction  and  suspension  in  con- 
nection with  the  Balkan  frame  (p.  657)  ma}^  also  be  employed. 
The  assumption  that  conformation  to  the  line  shown  in  Fig.  317A 
will  always  obviate  rotary  displacement  of  the  fragments  is  not  quite 
justified.    For  the  purpose  a  line,  which  in  a  general  way  corresponds 


766     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

to  the  one  indicated,  should  be  drawn  on  the  sound  leg  and  the  injured 
one  caused  to  conform  to  it. 

The  fracture  is  immohilized  with  the  knee  extended  and  the  foot 
placed  at  right  angles ;  both  must  be  included  in  the  dressing.  For 
the  first  week  lateral  splints  (tin  or  wood)  may  be  used.  At  the  end 
of  this  time,  necessary  reposition  is  made  under  narcosis  and  a  padded 
gypsum  dressing  is  applied.  At  the  end  of  another  eight  days,  this  is 
removed  and  the  fracture  is  held  in  place  with  gypsum  applied  directly 
to  the    (anointed)    skin.     In  this  way  lateral  deviation  is  usually 


Fig.  319. —  Extension  and  Counterextension  in  Fracture  of  the  Leg, 
Supplemented  by  Lateral  Traction. 


avoided;  rotation,  however,  is  likely  to  be  difficult  to  correct.  Over- 
extension at  the  site  of  the  fracture  must  be  avoided;  it  results  in 
healing  in  a,  curved  position.  This  is  very  likely  to  happen  during  the 
application  of  the  gypsum  dressing,  when  the  limb  is  held  above  and 
below  by  assistants ;  it  may  be  overcome  by  supporting  the  leg  from 
behind  with  the  hand  as  the  gypsum  is  applied. 

Cases  in  which  there  is  an  obstinate  tendency  on  the  part  of  the 
pointed  end  of  a  fragment  to  protrude  are  best  treated  with  the 
extension  apparatus  already  described  (p.  656),  which  requires  little 
modification  for  the  purpose. 


SPECIAL  FRACTUKES 


767 


The  question  as  io  whether  fractures  of  this  sort  should  he  immo- 
hilized  in  gypsum  at  once  may  be  answered  as  follows:  It  is  possible 
to  do  so  but  it  requires  considerable  skill  and  some  experience.  When 
the  fracture  is  seen  veiy  early  (a  few  hours  after  the  injury)  a  well 
padded  gypsum  dressing,  which  allows  for  swelling,  may  be  used.  If 
reposition  is  possible  at  this  time,  the  swelling  will  be  very  slight  and 
the  gypsum  does  no  harm.  As  this  is  not  often  possible  (except,  per- 
haps, in  transverse 
fractures)  it  is  best  to 
use  lateral  splints  until 
the  eighth  day  follow- 
lowing  the  injur}^ 

Ainhulatory  appara- 
tus in  the  treatment  of 
fractures  of  the  leg 
may  be  used  in  cases  in 
which  complete  repo- 
sition of  the  fragments 
is  attained  early  and 
when  there  is  not  much 
swelling  and  subcu- 
taneous contusion  of 
the  soft  parts.  The 
method  is  only  possible 
in  the  hands  of  the  ex- 
perienced surgeon  who 
possesses  especial  me- 
chanical skill  or  has 
the  ser^'ices  of  a  ''tech- 
nician" at  his  dispo- 
sition. For  the  purpose,  the  Thomas  splint  (p.  750)  or  similar  appa- 
ratus may  be  used.  The  circular  gypsum  dressing  shown  in  Fig.  320A 
may  be  used  for  fractures  in  the  middle  or  upper  portions  of  the  leg. 
For  fractures  near  the  malleoli,  the  dressing  shown  in  Fig.  320B  may 
be  employed.  In  either  instance  the  leg  is  padded  and  the  g^-psum  is 
very  thickly  applied  and  reinforced  with  embedded  strips  of  sheet  iron 
or  the  like.  By  the  exercise  of  ingenuity  the  dressing  may  be  made 
removable  and  the  leg  subjected  to  massage,  bathing,  and  carefully 
executed  passive  motion  at  frequent  intervals. 


Fig.  320. —  A,  GYPSUii  Dressing  for  Ambulatory 
Treatment  of  Fracture  of  the  Middle  and 
Upper  Portions  of  the  Leg;  B,  Similar  Appa- 
ratus  for   Fractures   above  the   Malleoli. 


768     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  prog?iosis  iu  this  class  of  cases  is  lamentably,  and  perhaps 
avoidabi}',  bad.  As  a  rule,  careful  therapy  is  followed  by  healing 
without  appreciable  deformity  and  almost  complete  return  of  function. 
Yet,  so  many  of  them  present  edema,  stiffness  and  deformity !  The 
reader  is  reminded  that  attention  to  detail  and  the  early  use  of  mas- 
sage, etc.,  are  necessary  to  a  favorable  outcome. 

Isolated  Fracture  of  the  Shaft  of  the  Tibia. —  This  fracture 
is  not  uncommon.  This  is  easily  understood  when  it  is  remembered 
that  the  fibula  is  usually  secondarily  fractured  (see  above)  and  that 
the  tibia  is  chiefly  concerned  in  supporting  the  body,  the  fibula  serv- 
ing simply  for  the  attachment  of  muscles  and  as  a  ''brace"  for  the 
ankle  joint.  As  a  rule,  the  lesion  is  a  torsion  fracture,  though  bending 
fractures  do  occur. 

The  diagnosis  in  oblique  fractures  is  easily  made  by  palpation, 
despite  the  fact  that  the  intact  fibula  acts  as  a  sort  of  splint  and  makes 
the  classic  .symptoms  of  fracture  less  manifest.  In  transverse  frac- 
tures the  diagnosis  is  cliificult  and  may  not  be  made  until  the  Ront- 
genogram  is  consulted.  When  a  fracture  of  the  tibia  is  attended  with 
much  luxation  of  the  fragments,  the  fibula  must  be  broken  or  luxated. 
As  the  fibula  is  often  fractured  at  a  different  level  (usually  higher 
up)  from  the  tibia  the  injur}-  often  escapes  recognition  (Fig.  317B). 

Reposition  is  easily  attained  by  manipulation,  which  also  reduces 
the  luxated  fibula.  Fixation  as  in  fracture  of  both  bones  of  the  leg. 
Ambulatory  treatment  is  not  objectionable  when  the  tibia  is  fractured 
transversely  and  the  fibula  is  uninjured. 

Isolated  Fractures  of  the  Fibula. — These  are  very  unusual.  The 
diagnosis  is  made  by  means  of  the  Rontgenogram.  Treatment  on 
general  principles. 

Fractures  of  the  Leg  at  Its  Lower  End. — In  discussing  fractures  of 
both  bones  of  the  leg  at  its  lower  portion,  a  certain  terminology  is 
employed  which  refers  to  forcible  movements  of  the  foot,  as  follows : 
Dorsal  and  plantar  flexion;  lateral  movements  of  the  foot  outward 
(abdiiction  or  pronation)  or  inward  (adduction  or  supination)  which 
act  upon  the  posterior  sector  of  the  root  of  the  foot  (talotarsal  joint) 
and  upon  the  lateral  ligaments  of  the  talocrural  joint.  In  addition 
to  this,  a  movement  may  be  executed  in  a  rotary  direction,  i.  e., 
around  the  long  axis  of  the  leg  (perpendicular  axis)  and  is  responsible 
for  a  certain  class  of  injury. 

Supramalleolar  Fracture  of  Both  Bones  of  the  Leg. —  (Fig. 
321). —  Supramalleolar  fracture  of  both  bones  deserves  special  con- 


SPECIAL  FRACTURES 


769 


sideration.  It  is  caused  by  direct  or  indirect  violence  (forcible  abduc- 
tion or  adduction)  and  by  torsion  of  the  foot  in  which  the  line  of 
fracture  usually  extends  into  the  ankle  joint. 

The  diagnosis  of  a  supramalleolar  fracture  as  such  is  not  difficult ; 
the  deformity  is  usually  severe  and  is  that  of  a  valgus  or  varus  posi- 
tion.   The  distal  fragment  may  be  displaced  backward. 

EcpositioH  of  the  fragments  (which  is  not  difficult)  is  followed  by 
fixation  of  the  foot  and  knee  joint.  Overcorrection  must  be  guarded 
against.  The  backward  displacement  of  the  lower  fragment  must  be 
given  special  treatment ;  this  is  taken  up  in  connection  with  fractures 
of  the  malleoli. 


Pig.  321. —  A,  Xormal,  Left  Leg   from  Behind;    B,   Supramalleolar 
Fracture  from  Behind;  C,  the  Injured  Leg  from  in  Front. 


Healing  with  deformity  is  especially  visible  from  behind.  Correc- 
tion following  osteoclasis  or  osteotomy  is  possible. 

Fractures  of  the  ]\Ialleoli. — Fractures  of  the  malleoli  form  a 
group  by  themselves  and  are  of  great  practical  importance.  They  are 
caused  hy  indirect  force  in  which  the  foot  is  subjected  to  forcible  move- 
ment in  the  ankle  joint  in  the  sense  of  pronation  or  supination  or  in 
the  sense  of  rotation  (eversion  or  inversion).  However,  for  practical 
purposes,  fractures  in  this  location  are  best  divided  into  luxation 
fractures  and  distortion  fractures.  In  the  former  the  foot  is  dis- 
located, in  the  latter  the  ankle  joint  is  distorted.  The  two  groups 
have  in  common  the  following :  They  are  both  caused  by  indirect 
violence;  both  are  attended  with  fracture  of  one  or  both  malleoli  and 


770    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


<,yith  injury  of  the  ligaments  of  the  ankle  joint,  which  varies  from 
fiimple  stretching  to  laceration,  and  luxation  of  the  joint.  Direct 
violence  is  almost  never  the  causative  factor.  In  the  treatment  it  is 
important  to  remember  that 
the  injury  involves  the  joint 
and  that  the  early  use  of 
massage  and  passive  motion 
has  a  determining  influence 
upon  the  outcome.  First  of 
all,  exact  reposition  is  esse^i- 
tial.  This  is  accomplished 
by  traction  upon  the  heel, 
followed  by  forcible  correc- 
tive movements  of  the  foot. 
Mevision  of  the  position  of 
the  fragments  at  the  end  of 
one  week  is  imperative. 

The  typical  malleolar  frac- 
ture ("fracture  de  Dupuy- 
tren"  of  the  French; 
"Pott's  fracture"  of  the 
English  and  Americans)  is, 
in  a  way,  analogous  to 
"Colics'  fracture"  at  the 
wrist.  The  involvement  of 
the  fibula  in  fractures  near 
the  ankle  joint  is  explained 
by  the  intimate  association 
of  this  bone  with  the  lower 
end  of  the  tibia  (ligaments, 
etc.). 

The  typical  malleolar  frac- 
ture is  caused  by  a  sudden 
"kinking"  of  the  body  with 
the  foot  fixed  or  by  a  sud- 


FiG.     322. —  A,    Artificial    Prep.vration  ; 

THE  Ankle  Joint  Opened  from  Above. 

The  internal  malleolus  is  avulsed  and 
connected  Avith  the  deltoid  ligament,  which 
is  attached  to  the  root  of  the  foot.  The 
anterior  and  posterior  tibiofibular  ligaments 
have  also  avulsed  small  fragments  of  bone 
from  the-  outer  aspect  of  the  articular  end 
of  the  tibia;  the  external  malleolus  is 
separated  from  the  tibia  as  a  result  of  a 
fracture  of  the  fibula  higher  up.  The  latter 
is  a  bending  fracture. 

B,  Frontal  Longitudinal  Section 
Through  the  Bones  of  the  Foot  and 
Leg. 

The  specimen  is  similar  to  that  shown  in 
A.  The  bonding  fracture  of  the  fibula  is 
well  defined. 


den  outward  "kinking"  of 
the  foot.  The  outward  movement  {pronation)  of  the  foot  in  the  talo- 
crural joint  creates  great  tension  of  the  inner  lateral  ligament ;  when 
this  movement  is  continued,  the  ligament  does  not  tear  but  the  tip  of 
the  malleolus  is  avulsed,  the  foot,  as  a  whole,  is  crowded  against  the 


SPECIAL  FRACTURES 


771 


outer  malleolus  and  fractures  it.    In  many  instances  the  weight  of  the 
body  (not  the  pronating  force)  fractures  the  fibula. 

Symptoms. — In  typical  fractures  the  tip  of  the  internal  malleolus 


B 


C  D 

Fig.  323. —  Malleolar  Fractures;  A,  Malleolar  Fracture  Healed  with 
Deformity,  i.e.,  Traumatic  Flat  Foot;  B,  Posterior  View  of  A,  Show- 
ing THE  Angular  DE\^ATION  in  the  Long  Axis  of  the  Leg  and  Heel;  C, 
Backward  Subluxation  of  the  Foot  in  Typical  Malleolar  Fracture; 
D,  Phantom  op  C. 


is  found  abnormally  movable  and  luxated  downward,  and  the  fibula  is 

fractured  above  the  malleolus.     "With  the  foot  hold  in  one  hand  and 
the  leg  fixed  with  the  other,  abnormal  lateral  mobility,  especially  in 


772     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


the  direction  of  pronation  of  the  foot,  may  be  demonstrated.     The 
foot  is  postured  in  the  valgus  positiori. 

At  times,  the  edge  of  the  broken  tibia  makes  i^ressure  against  the 
overlying  skin  which  is  likely  to  be  very  much  thinned  out  and  tense. 
But  little  additional  trauma  is  required  to  rupture  the  skin  in  this 
situation  so  that  a  compound  fracture  dislocation  is  produced.  Occa- 
sionally the  protruding  end  of  the  tibia  incarcerates  the  edge  of  the 
perforated  skin,  making  it  necessary  to 
divide  it  in  order  to  accomplish  repo- 
sition (Fig.  324). 

The  characteristic  ^'kinking"  of  the 
fibula  above  the  malleolus  is  always 
more  or  less  manifest.  The  mobility  of 
the  fibular  fragment  is  easily  demon- 
strable by  manipulation ;"  however,  this 
is  very  painful,  and  as  consideration  of 
the  mechanism  of  the  fracture  and  in- 
spection of  the  deformity  as  a  whole  lead 
to  a  conclusion  in  this  connection,  there 
would  seem  to  be  no  need  of  the  demon- 
stration except  when  the  patient  is 
narcotized.  It  is  suggested  that  prac- 
titioners bear  this  in  mind.  This  is  also 
true  regarding  crepitus. 

It  is,  however,  important  that  the 
exact  anatomical  conditions  be  recog- 
nized. The  inner  malleolar  fragment 
may  be  very  small.  The  fracture  of  the 
fibula  (in  the  manner  described)  is  only 
possible  when  the  tense  ligaments  be- 
tween the  tibia  and  the  fibida  are  torn 
at  the  lower  end  of  the  latter.    At  times, 

the  fracture  at  the  lower  end  of  the  tibia  is  oblique  and  extends  into 
the  joint;  at  others,  only  a  moderate  amount  of  the  tibia  (at  its 
fibular  side)  is  avulsed,  and,  in  some  instances,  the  ligaments  are  torn 
Mdthout  any  solution  of  continuity  of  the  tibia  in  this  situation. 

Clinically,  it  is  important  to  remember  that  in  some  of  these  cases 
the  function  of  the  joint  is  not  entirely  lost  and  that  the  injured 
person  is,  at  times,  capable  of  locomotion,  although  this  is  accom- 
plished with  considerable  difficulty. 


Tig.  324. —  Compound  Malleo- 
lar Fracture,  Showing  In- 
carceration OF  THE  Lower 
Edge  op  the  Wound. 


SPECIAL  FRACTURES 


773 


In  estimating  the  prognosis  it  is  necessary  to  regard  the  injury  as  a 
grave  one.  The  lesion  is  a  genuine  articular  fracture,  and  is  especially 
important,  as;  its  site  is  concerned  in  supporting  the  entire  weight  of 
the  body.  It  is  with  chagrin  that  the  writer  states  that  the  unfavor- 
able outcome  seen  in  many  cases  is  due  to  faulty  methods  of  treatment. 
The  treatment  is  primarily  directed  toward  exact  reposition  of  the 
fragments.  The  foot,  as  a  whole,  must  be  pushed  toward  the  tibia. 
Placing  the  foot  in  a  varus  position  with  the  view  of  obviating  a 
threatened  valgus  position  is  not  necessary  nor  advisable.     the 

reposition  must  be  exact  and  the 
*'kink"  in  the  fibula  simply  oblit- 
erated. This  is  accomplished  by  firm 
lateral  pressure  on  the  fibula  toward 
the  tibia,  or  by  compression  of  both 
malleoli.  In  severe  cases,  with  a 
tendency  to  recurrence  of  the  de- 
formity, it  is  permissible  to  nail  the 
fibula  fragment  to  the  tibia.  It  is 
important  to  correct  the  posterior 
luxation  of  the  foot  by  traction. 

When  reposition  is  accomplished 
(under  narcosis),  the  foot  is  placed 
at  right  angles  to  the  leg,  in  a  posi- 
tion which  will  permit  of  subsequent 
locomotion,  and  both  are  immobilized 
in  splints  for  a  few  days.  At  the 
end  of  this  time,  the  splints  are 
removed  and  appropriate  gj'psum 
dressing  is  applied.  In  order  to 
make  the  seat  of  the  injury  access- 
ible for  purposes  of  massage  and  passive  motion,  the  gjT^sum 
dressing  may  be  arranged  accordingly,  i.  e.,  a  removable  ambulatory 
splint  maj^  be  fashioned.  As  already  stated,  the  use  of  apparatus  of 
this  sort  is  feasible  only  under  conditions  not  available  in  practice, 
and  before  it  can  be  constructed  the  fracture  is  usually  healed.  With 
this  in  view  the  gypsum  dressing  is  slit  open  so  that  it  may  be  removed 
for  the  purpose  of  massage  and  passive  motion  and  then  reapplied. 
During  the  first  fourteen  days  the  dressing  is  removed  every  three  to 
four  days,  after  this,  every  two  days.  If  the  gj'psum  dressing  is 
broken  a  new  one  is  applied.     In  this,  special  care  must  be  taken  to 


Fig.         325. —  EONTGENOGRAM        OP 

Typical  ]\Iallbolar  Fracture 
FROM  IN  Front  (Harlem  Hos- 
pital case). 


774    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


prevent  return  of  deformity  and  attention  given  to  the  correction  of 
minor  faults  in  reposition.  The  early  use  of  mechanicotherapy  is 
advisable . 

When  primary  manual  reposition  is  difficult  and  release  of  the 
pressure  and  traction  is  followed  by  return  of  the  malposition,  the  old 
method  of  Dupuytren  may  be  used.  The  accompanying  illustration 
(Fig.  326)  speaks  for  itself.  Care  must  be  taken  to  guard  against 
overcorrection  which  results  in  a  ''club  foot"  deformity. 

Extension  as  ordinarily  employed  does  not  overcome  the  difficulty. 
However,  nail  extension  is  an 
exceedingly  useful  measure  of 
relief  in  these  cases.  In  addi- 
tion to  this,  the  method  of 
Riicker,^"  in  which  extension  is 
very  ingeniously  applied  to  the 
foot,  may  be  advantageously 
used.  The  method  of  applying 
the  extension  is  shown  in  Fig. 
327,  and  may  also  be  used  in 
connection  with  the  Balkan 
frame  (p.  657)^ 

When  a  fracture  of  this  sort 
is  healed  in  a  faulty  position, 
immediate  corrective  operative 
relief  is  indicated.  Delay  is 
attended  with  increasing  loss 
of  function. 

Double  malleolar  fracture  is 
caused  by  forcible  supination 
of  the  foot;  the  external  mal- 
leolus is  avulsed,  the  foot  is 
forced  into  varus    position,  and  the  internal  malleolus  is  torn  off. 

The  lesion  is  rare.  Occasionally,  trauma  in  this  region  produces  a 
longitudinal  fracture  of  the  tibia. 

Careful  examination  reveals  the  nature  of  the  injury.  The  treat- 
ment is  similar  to  that  of  typical  malleolar  fracture. 

Epiphyseal  Separation  at  the  Lower  End  of  the  Bones  of  the 
Leg. —  This  is  a  rare  injury  occurring  in  children.  It  occasionally 
happens  in  forcible  correction  of  club  foot.     The  diagnosis  is  readily 


Fig. 


326. —  Dupuytren  's  Splint  for  Typi- 
cal Fracture  of  the  Malleoli. 


SPECIAL  FRACTURES 


775 


made  by  eliciting  false  motion  and  soft  crepitus.     Reposition  is  easy ; 
fixation  as  in  malleolar  fracture. 

The  Isolated  Fractures  of  the  Tibia  and  of  the  Fibula. —  Supra- 
malleolar and  malleolar  fractures  are  caused  by  indirect  violence  in 

the  same  way  as  is  de- 
scribed in  connection  with, 
typical  malleolar  fractures, 
except  that  the  provocative 
force  is  less  severe  and  is 
directed  against  only  one 
of  the  bones. 

Isolated  fracture  of  a 
malleolus  is  comparatively 
frequent ;  isolated  supra- 
malleolar fractures  are 
rare. 

The  clinical  examination 
is  not  always  satisfactory-; 
however,  pain  on  lateral 
motion  of  the  foot,  pressure 
and  impact  pain  should  be 
regarded  as  suspicious  in 
this  connection.  The  Ront- 
genogram  decides  the  diag- 
nosis. In  doubtful  cases 
the  treatment  of  fracture 
should  be  carried  out. 

Fractures  of  the  Foot. — 
Fracture  of  the  talus  alone 
is  probably  rare.  Usually, 
it  appears  in  consort  with 
severe  injuries  of  the  talo- 
crural joint  or  of  the  root 
of  the  foot.  Infractions 
a  n  d  avulsion  fractures 
occur  in  connection  with 
luxations  of  the  foot.  Fractures  of  the  calcaneum  are  often  compli- 
cated b}^  those  of  the  talus,  especially  its  neck.  The  symptoms  are,  of 
course,  largely  dependent  upon  the  attendant  injury  and  are  not 
very  clearly  defined.     However,  visible  deformation  of  the  outline  of 


Fig.    327. —  Extension   Apparatus    for   Mal- 
leolar  Fracture. 

The  lower  "  boot  pull  "  above  and  the 
upper  ' '  boot  pull  ' '  below.  These  two  are 
combined  witli  the  ' '  main  longitudinal  ex- 
tension. ' '  Weight  applied  to  the  three  straps 
corrects  the  deformity  at  the  same  time. 


776     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


the  foot,  swelling  on  its  dorsum,  pain  and  tenderness  on  pressure, 
thickening  and  interference  with  motion,  especially  flexion,  and 
measurements  of  the  talus  circle,  are  likely  to  lead  to  the  diagnosis, 
though  no  doubt  the  Rontgenogram  will  usually  have  to  be  depended 
upon  to  clear  up  the  situation.  The  latter  must  be  carefully  and 
properly  made.  The  treatynent  is  carried  out  on  general  principles. 
Fractures  of  the  Calcaneus. —  These  are  divided  into  those  of  the 
body,  and  of  its  processes,  which  latter  consist  of  the  posterior  (tuber 
calcis),  anterior  (capitulum  calcanei),  medialis  (sustentaculum),  and 
lateralis  (processus  trochlearis). 

A  compression  fracture 
of  thecalcaneum  is  caused 
by  a  fall  or  leap  upon  the 
foot  (masons,  roofers, 
painters,  athletes,  etc.). 
The  bone  is  crushed  by 
the  talus  which  compresses 
the  calcaneus  (crushing 
fracture).  As  a  rule,  a 
longitudinal  fracture  of 
the  upper  aspect  of  the 
bone  occurs,  though  not 
infrequently  a  number  of 
radiating  fissures  are  pro- 
duced. In  severe  cases  of 
this  sort  characteristic 
symptoms  are  presented. 
The  calcaneus  is  broad- 
ened, flattened  and  pain- 
f ul  ;  the  malleoli, 
especially  the  inner,  are  nearer  the  ground;  flat  foot  is  frequent. 
Motion  in  the  talocrural  joint  is  free ;  on  the  other  hand,  pronation  and 
supination  of  the  foot  is  restricted. 

At  times,  the  diagnosis  is  easier  in  old  cases  than  in  recent  ones,  the 
callus  formation  and  secondary  changes  accentuating  the  deformity. 
Aside  from  the  broadening  of  the  heel,  the  obliteration  of  the  con- 
cavity to  either  side  of  the  tendo  Achillis,  atrophy  of  the  muscles  of 
the  calf,  marked  interference  with  motion,  pain,  deformity,  and 
lowering  of  the  malleoli  are  characteristic. 


B 


Compression"    Fracture    of   the 
Left  Calcaneus. 


Note  sinking  of  malleoli. 

B,  Normal  Sister  Foot. 


SPECIAL  FRACTUKES 


777 


Fractures  of  this  sort  are  more  frequent  than  has  been  believed. 
They  are  easily  mistaken  for  so-called  sprains. 

The  prognosis  is  not  good.  Even  in  cases  given  early  treatment,  the 
function  of  the  foot  is  impaired  for  a  long  time  and  may  be  perma- 
nently interfered  with.  This  is  no  doubt  due  to  the  fact  that  injuries 
of  the  heel  bone  are  often  complicated  by  lesions  of  the  malleoli  and 
other  bones  of  the  foot  not  recognized  at  the  time. 

Reposition  should  be  accomplished  if  possible;   this  is  followed  by 


J 

■5    1 

W  1 

Fig.  329. —  Rontgexogram  of  Typical  Compression  Frac- 
ture OF  THE  Calcaneus. 

The  perpendicular  diameter  of  the  foot  is  visibly  short- 
ened.    The  deformity  is  permanant  (Harlem  Hospital  case). 

prolonged  immobilization  in  a  gypsum  dressing.  Early  locomotion 
favors  flat  foot.  In  the  early  stages  the  danger  of  fat  embolism  makes 
massage  dangerous ;   it  may  be  used  after  the  second  week. 

Fracture  of  the  tuherosity  of  the  calcaneum  (Fig.  330)  is  rare.  It 
occurs  in  the  form  of  an  avulsion  fracture  (sudden  violent  action  of 
the  muscles  of  the  calf)  or  may  be  ''crushed  off"  by  direct  violence. 
It  also  occurs  as  a  part  of  a  compression  fracture  of  the  entire  bone. 
The  fragment  is  luxated  upward  by  the  action  of  the  gastrocnemius 


778     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


muscle.  Reposition  of  the  fragment  may  be  accomplished  by  flexing 
the  knee;  it  should  be /ia;ed  by  nailing,  humohilization  (in  gypsum) 
with  the  foot  fully  extended  and  the  knee  flexed  is  essential.  In  order 
to  bring  the  fragment  in  place  it  may  be  necessary  to  divide  the  tendo 
Achillis. 

Fracture  of  the  sustentaculum  tali  consists  of  a  separation  of  the 
bony  prominence  upon  which  the  inner  side  of  the  talus  rests ;  it 
forms  the  lower  edge  of  the  sulcus,  giving  passage  to  the  tendon  of 
the  flexor  hallucis.  The  lesion  is  attended  with  tenderness  in  this 
situation ;  the  talus  is  luxated  downward  and  inward ;  the  foot  is 
in  the  valgus  position,  flexion  and  exten- 
sion of  the  foot  in  the  talocrural  joint  is 
slightly  restricted;  its  abduction  and 
adduction  (active)  is  much  impaired. 

In  older  cases,  bony  thickening  at  the 
sustentaculum  (beneath  the  internal 
malleolus)  is  easily  palpated.  The  callus 
often  causes  the  latter  to  become  firmly 
attached  to  the  talus. 

Isolated  fracture  of  the  sustentaculum 
is  rare ;  it  may  be  produced  by  forcible 
supination  or.  pronation  of  the  foot 
("turning  the  ankle").  It  is  not  infre- 
quently fractured  in  connection  with 
lesions  of  the  body  of  the  calcaneus  and 
the  inner  malleolus. 

Fracture  of  the  anterior  process  may 
be  a  part  of  a  compression  fracture  of 
the  calcaneum  and  may,  though  rarely, 
take  place  alone.  The  adjacent  cuboid 
may  be  simultaneously  broken  or  luxated. 

Fracture  of  the  inframalleolar  process  (trocuicaris)  may  be  due  to 
direct  "crushing  off"  or  may  result  from  the  drag  of  the  calcaneo- 
fibular  ligament  (avulsion  fracture).  It  is  probable  that  the  latter 
does  not  occur  as  often  as  has  been  generally  believed.  The  peroneal 
tendons  are  very  likely  to  be  injured. 

The  foot  is  fixed  in  the  normal  position  for  a  long  time. 

Fracture  of  Other  Bones  of  the  Foot. —  Fractures  of  the  other 
bones  of  the  foot  are  not  easily  diagnosticated.  As  a  rule,  the  Ront- 
genogram  must  be  resorted  to.     Reposition  is  not  always  easy  and  may 


Fig.  330. —  Fracture  of  the 
Tuberosity  of  the  Cal- 
caneus. 

The     posterior 
luxated  upward. 


fragment    is 


SPECIAL  FRACTURES 


779 


demand  operative  measures  of  relief.  Fixation  for  a  long  time  is 
essential  to  return  of  function.  Operative  measures  of  relief  give 
excellent  results. 

Fractures  of  the  metatarsal  hones,  since  the  advent  of  the  X-ray, 
have  been  found  to  be  more  common  than  has  been  believed.     At 


Fig.  331. —  Rontgexogram  of  Fracture  of 
THE  Second  Metatarsal  Boxe  (Harlem 
Hospital  case). 

times,  they  occur  in  connection  with  seemingly  slight  trauma.  The 
practitioner  is  admonished  to  have  his  so-called  "sprains"  and 
"strains"  of  the  foot  subjected  to  Rontgenographic  examination. 
Once  the  diagnosis  is  made,  reposition  and  fixation  are  carried  out  on 
general  principles.  While  locomotion  should  not  be  permitted  for  a 
long  time,  early  massage  and  passive  motion  are  advisable.  After 
union  has  taken  place  special  footgear  should  be  worn. 


780     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

BIBLIOGRAPHY 

1.  KocHER.     Mitt.  a.  d.  Grenzgebiet,  etc.,  Jena,  1896,  i. 

2.  QuETSCH.     Die  Verletzungen  der  WirbelsJiule,  etc.,  Berlin,  1914. 

3.  Frazier.     Surg,  of  the  Spinal  Cord.,  Appleton,  New  York  and  London, 

1918. 

4.  ScHULTE.     Deutsch,  mil-arzt.  Zeitsehr.,  1902,  xxxi. 

5.  KiJTTNER.     Berlin  klin.  Woeh.,  1908,  xlv. 

6.  V.  Kryger.     Deutsch.  Zeitsehr.  f.  Chir.,  1897,  Ixv. 

7.  Delbet.     Bull.  et.  mem.  Soc.  de  Chir.  de  Paris,  1900,  xxvi. 

8.  Ehrlich.     Deutsch.  Zeitsehr.  f.  Chir.,  1908,  xcii. 

9.  EwALD.     Fortschr.  a.  d.  Geb.  d.  Rontgenstrahl.,  1913-1914,  xxi. 

10.  Taylor.     Ann.  Surg.,  Phila.,  1911,  liii. 

11.  KiLiANl.     Ann.  Surg.,  Phila.,  1912,  Iv. 

12.  GuRLT,     Handb.  d.  Lehre.  v.  Knochenbriiche,  Hamburg,  1862, 

13.  Milner.     St.  Bartholemew's  Hosid.  Report,  London,  1874,  x. 

14.  Gibson.     Lancet,  London,  1885,  ii.    . 

15.  Malgaigne.     Traite  des  fraet.  et  des  lux.,  Paris,  1847-1865. 

16.  Wagner  and  Stolper.     Deutsch.  Chir.,  Stuttgart,  1898,  Lief  40. 

17.  Corner.    Ann.  Surg.,  Phila.,  1917. 

18.  MiXTER.     Ann.  Surg.,  Phila.,  1910. 

19.  Walton.     Internat.  Clinics,  Phila.,  1892,  ii. 

20.  Stanley.     Quoted  by  Frazier,  No.  3. 

21.  Blasius.     Vierteljahi-sehr.  f.  prakt.  Heilkunde,  Prague,  1869,  cii. 

22.  BORCHARDT.     Arch.  f.  klin.  Chir.,  1914,  cv. 

23.  ScHMiD.     Fortschr.  a.  d.  Geb.  d.  Rontgenstrahl.,  Hamburg,  1911-1912, 

xvii. 

24.  Helferich.     Atlas,  d,  traum  Fract.,  etc.,  Munich,  1914. 

25.  Albers.     Quoted  by  Helferich,  No.  24. 

26.  Glassner.     Therap.  Mon.,  1910. 

27.  Middledorp.     Quoted  by  Helferich,  No.  24. 

28.  Blake.     Fractures,  D.  Appleton  &  Co.,  N.  Y.  and  London,  1919. 

29.  LORENZ.     Deutsch.  Zeitsehr.  f.  Chir.  Bd.  78. 

30.  Stolper.     Deutsch.  Zeitsehr.  f.  Chir.,  Ixxvii. 

31.  KocHER.     Quoted  by  Helferich,  No.  24. 

32.  Buck.     Quoted  by  v.  Volkmann  in  Pitha-Billroth's  Handb. 

33.  Bardenheuer.     Stuttgart,  1890. 

34.  Heusner.     Deutsch.  Zeitsehr.  f.  Chir.,  Ixxx. 

35.  Whitman.     Med.  Record,  March  10,  1904. 

36.  DA\aDS0N  and  Smith.     Autoplastic  Bone  Surg.,  N.  Y.  and  Phila.,  1916. 

37.  H.  0.  Thomas.     Quoted  by  Helferich,  No.  24. 

38.  VoLKER.     Arch.  f.  klin.  Chir.,  xxxvii. 

39.  RiJCKER.    Zentrbl.  f.  Chir.,  1910,  No,  4. 


CHAPTER  VI 

OPEEATIONS    OX  BOXES   AXD   JOINTS 

OPERATIONS  ON  BONES 

General  Considerations. —  While  there  are  a  number  of  bone  lesions 
amenable  to  surgical  efforts  at  relief  in  which  bone  forceps,  rongeur, 
gouge,  mallet,  scoop  and  spoon,  etc.,  may  be  made  to  meet  the  indica- 
tions, there  are  few  in  which  the  modern  electrically  driven  instru- 
ments will  not  serve  a  purpose  not  met  by  the  "hand  tools."  It  is 
true  that,  if  you  give  a  surgical  problem,  and  confine  the  surgeon  to 
either  the  "hand  tools"  or  to  those  electrically  driven,  he  will  best 
meet  the  indications  with  the  former;  yet  there  is  no  doubt  that  he 
will  best  accomplish  the  intent  if  he  is  armed  with  both. 

In  addition  to  the  instruments  used  in  all  operations  (knives,  scis- 
sors, forcipressure,  etc.),  those  shown  in  Fig.  332  are  used  in  opera- 
tions upon  bones. 

According  to  Albee\  the  surgical  electromotor  outfit  (Fig.  333) 
should  fill  the  following  requirements: 

1.  It  should  permit  of  the  thorough  and  rapid  sterilization  of 
every  part  which  comes  in  contact  with  the  surgeon  or  the  field  of 
operation,  including  the  electric  cable  for  transmitting  the  power. 

2.  It  should  permit  of  ready  application  to  all  types  of  bone  opera- 
tions, whether  situated  superficially  or  in  a  deep  wound. 

3.  It  should  permit  of  accurate  control  and  guidance  of  the  motor 
cutting  tools  in  all  wounds. 

4.  It  should  permit  of  easy  and  accurate  control  of  the  motor 
power. 

5.  The  motor  instruments  should  be  held  in  place  in  the  motor  by 
a  mechanism  which  permits  of  their  speedy  interchange. 

In  the  outfit  described  (Albee's^)  the  motor  is  covered  b}'  an  adjust- 
able shell,  enabling  the  surgeon  to  hold  the  motor  in  his  hands  while 
the  tool  is  cutting.  It  has  been  found  impossible  to  construct  a  light 
motor  which  will  resist  deterioration  from  repeated  boiling  of  the 

781 


782     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Fig,  332. —  a,  Murphy's  Joint  Tools;  6,  Roxget-r;  c,  Loumann's  Bone  Hold- 
ing Forceps  ;  d,  Lion  Jaw  Forceps  ;  e.  Bone  Spreader  ;  /.  Bone  Cutting 
Forceps;  g,  Gouges;  h,  Forceps  for  Passing  Instruments;  i,  Chisels; 
j,  GiGLi  H artel  Saw;  k,  Bone  Drills;    I,  Mallet. 


OPERATIONS   ON  BONES  AND   JOINTS 


783 


motor  itself  or  aiiy  safe  type  of  sterilization.     Therefore,  the  Hartley- 
Kenyon  method  of  removable,  sterilizable  shells  is  used. 

The  apparatus  consists  of  a  small  portable  motor  with  a  sterilizable 
shell  divided  into  two  parts  which  permits  of  boiling.  A  guide  handle, 
also  sterilizable  by  heat,  is  adjusted  at  right  angles  to  the  small  end 
of  the  motor  over  the  shell.  A  foot  switch  is  used  to  make  and  break 
the  electric  current. 

Cutting  Instruments. —  The  single  {circular)  saw,  about  li/'2"  in 
diameter,  with  graduated  washers  or  guards,  is  very  thin  and  is  held 
on  the  shaft  by  means  of  nuts. 

The  twin  saw  is  so  constructed  that  it  can  be  adjusted  to  any  desired 

width.  Each  saw  is 
mounted  on  a  separate 
shaft,  one  shaft  is  hollow, 
so  that  the  other  may  be 
telescoped  within  it  and 
thus  bring  the  saws  at  any 
distance  apart,  according 
to  the  size  of  the  bone 
being  operated  upon  and 
the  width  of  the  graft  or 
gutter  to  be  formed. 

The  dowel  instrument,  or 
lathe,  is  fastened  into  the 
motor  by  the  automatic 
catch.  The  size  of  the  bone 
dowel,  or  nail,  is  regulated 
b}'  the  size  of  the  cutter, 
which  is  adjusted  into  the 
lathe.  The  dowel  shaper  is  used  by  first  inserting  it  into  the  motor 
and  then  placing  the  apparatus  parallel  with  and  on  the  edge  of  the 
instrument  table.  While  the  assistant  steadies  the  motor  and  lathe, 
the  surgeon,  holding  (with  a  clamp)  the  strip  of  bone  to  be  shaped, 
pushes  it  into  the  dowel  cutter. 

The  small  satv  is  used  for  cutting  the  ends  of  the  graft  or  strip  of 
bone  which  is  being  removed. 

The  guard  with  spray  is  coimected  with  a  container  by  a  sterile 
rubber  tube  by  means  of  which  a  constant  spray  of  saline  solution  is 
played  on  the  saw,  preventing  friction  heat  and  dissemination  of  fluid 
and  bone  particles. 


Fig. 


333. —  Albee's  Surgical  Electromotor 
Outfit. 


784     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  twist  drills  are  of  the  metal  drill  type. 

The  electric  motor  is  made  available  in  the  sterile  field  as  follows: 
The  parts  to  be  sterilized  are  removed  from  the  motor  by  releasing  the 
plunger  on  the  end  of  the  electric  cable  so  as  to  allow  it  to  come  out. 
This  part  of  the  conducting  elements,  back  to  the  union  on  the  con- 
necting cord,  is  boiled.  The  handle  and  shells  are  removed  and, 
together  with  the  cutting  insftruments,  are  sterilized  by  boiling. 


STEKILC 


Fig.  334. —  First  Step  in  Assembling 
Albee's  Motor  Outfit. 
The  shell  is  turned  to  the  left  until  it 
is  arrested,  and  the  arrow  on  the  shell  is 
aligned  with  the  one  on  the  motor.  The 
motor  is  then  inverted  and  comes  under 
the  control  of  the  surgeon.  (Redrawn 
from  Albee's  "Bone  Graft  Surgery.") 


Fig.  335. —  Second  Step  in  Assembly. 

While  the  surgeon  holds  the  motor  by 
the  sterile  shell,  already  attached,  the 
other  hal?  is  hooked  in  place.  (Redrawn 
from  Albee's  "Bone  Graft  Surgery.") 


OPERATIONS   OX  BONES   AND   JOINTS 


785 


After  sterilization,  the  long  section  of  the  shell  is  grasped  with  the 
hand  and  placed  on  the  corresponding  end  of  the  motor  which  is  held 
by  an  assistant  (non-sterile)  (Fig.  334).  The  operator  grasps  the 
sterile  half  shell  and,  placing  it  over  the  other  end  of  the  motor,  locks 
it  (Fig.  335).  The  guide  handle  is  placed  over  the  neck  of  the  motor 
and  fastened.  The  connecting  plunger  of  the  cable  is  then  inserted 
through  the  sleeve  on  the  shell,  into  the  motor.  In  operating  the 
motor  the  handle  of  the  assembled  outfit  is  held  in  the  operator's  right 

hand,  the  base  of  the  motor  is 
grasped  with  the  left ;  the  right  foot 
controls  the  foot  switch,  which  is 
placed  on  the  floor.  The  various 
technical  appliances  are  described 
and  illustrated  in  connection  with 
the  special  operations. 

Evacuation  of  Bone. —  This  term  is 
intended  to  cover  the  procedures 
varyingly  designated  as  gouging, 
curetting, draining,  partial  resection, 
sequestrectomy,  etc.  The  measure  is 
employed  for  the  purpose  of  remov- 
ing the  products  of  inflammatory 
processes  in  bone,  including  caries 
(tuberculosis,  lues,  etc.),  necrosis 
(osteomyelitis,  sequestra)  and  cysts 
(echinococcus,  etc.),  tumors  (osteo- 
mata,  sarcomata,  etc.)  and  foreign 
bodies. 

Evacuation  of  epiphyses  is  indi- 
cated when  the  pathological  process 
is  limited  to  these  sectors  of  the  bone. 
Taking  into  consideration  that  the 
circulatory  conditions  in  the  epi- 
physes favor  the  occurrence  of  hematogenous  processes  of  various 
kinds  in  these  situations  and  that  extension  to  contiguous  joints  fre- 
quently occurs,  the  early  evacuation  of  the  primary  focus  is  a  matter 
of  considerable  importance. 

The  technic  varies  somewhat  with  the  particular  epiphysis  attacked 
and  the  character  of  the  process  to  be  dealt  with.  The  incision  should 
be  so  located  as  to  give  ready  access  to  the  lesion,  permit  of  subsequent 


Fig.    336. —  Flap   with    Periosteum 
Turned  Vp  from  Tpper  Tibia. 


786     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

drainage  and  yet  not  involve  danger  of  injury'  to  important  anatom- 
ical structures ;  especial  care  should  be  taken  not  to  invade  the  joint, 
either  in  the  approach  or  while  removing  the  lesion.  As  a  general 
proposition,  the  "flap  approach"  (Fig.  336)  should  be  made  when  pos- 
sible. This  permits  of  dissecting  up  the  periosteum  with  the  flap. 
When  the  wound  is  sutured  the  periosteum  is  replaced  and  contributes 
to  regeneration  of  the  bone.  The  corticalis  is  perforated  with,  the 
trephine,  gouge  or,  preferably,  with  the  electrically  driven  conical  burr 
(Fig.  337) .  The  lesion  is  removed  with  the  gouge,  chisel,  and  spoon  or 
with  the  large  cylindrospherical  burr  (Fig.  341,  shown  in  connection 
with  hollowing  out  a  diaphysis) . 


Fig.    337. —  Perforation    of   the    Humerus   with    the   Electrically   Driven 

Conical  Burr. 


After  the  bone  cavity  is  dried,  it  is  either  fiUed  with  iodoform  wax 
(when  the  operation  is  done  for  tuberculosis,  p.  453)  or  is  allowed  to 
fill  with  blood  (when  done  for  tumor,  cyst  or  foreign  body),  or  it  is 
drained  and  the  flap  sutured  in  place  with  interrupted  sutures.  When 
a  considerable  extent  of  the  diameter  of  the  bone  is  removed,  tlie  part  is 
immobilized  in  g}"psum  to  prevent  fracture. 

Evacuation  of  the  diaphyses  is  executed  for  the  same  reasons  stated 
in  connection  with  the  epiphyses.  The  bone  is  widely  exposed,  the 
periosteum  is  turned  back  with  the  soft  parts.  The  shaft  of  the  bone 
is  opened  at  either  end  of  the  diseased  area  with  the  trephine,  gouge  or 


OPERATIONS  OX  BOXES  AXD   JOINTS 


787 


burr  (Fig.  337);  the  opening  is  enlarged  with  a  eylindrospherical 
burr  (Fig.  338).  A  similar  opening  is  made  at  the  other  end  of  the 
diseased  area  and  these  are  connected  b}'  removing  a  longitudinal  sec- 
tion of  bone  from  between  them  (Figs.  339-340).  Evacuation  of  the 
diseased  bone  is  now  proceeded  with.  Fig.  341  shows  the  method  of 
accomplishing  this  with  the  electrically  driven  eylindrospherical  burr. 
The  residual  cavity  and  the  soft  parts  are  treated  as  stated  in  connection 
with  evacuation  of  the  epiphysis. 


Fig.  338. — ■  Exlabgemext  of  the  Opexixg  with  the  Haxd  Dri\t:x  Cylixdro- 

SPHERicAL  Burr. 


Following  the  operaticn  the  stability  of  the  limb  is  much  lessened 
and  it  is,  therefore,  supported  in  a  gypsum  or  other  suitable  apparatus 
which,  at  the  same  timo,  permits  of  ready  access  to  the  wound ;  this  is 
especially  necessary  when  the  lower  limb  is  affected.  The  drainage 
material  may  be  removed  on  the  eighth  day.  "Wounds  of  this  sort 
usually  heal  very  slowly,  and  care  with  regard  to  cleanliness  is  impor- 
tant. At  the  end  of  the  second  week  the  apparatus  should  be  so 
arranged  that  it  may  be  entireh'  removed,  the  limb  massaged  (avoiding 


788     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

the  wound  area),  the  contiguous  joint  moved,  and  the  apparatus  reap- 
plied. For  the  purpose,  the  removable  gypsum  splint,  a  type  of  which 
is  shown  in  Fig.  229,  is  very  useful.  In  this  class  of  cases,  the  treat- 
ment of  the  underlying  cause  (tuberculosis,  lues)  isi  of  great 
importance. 

Osteoclasis  consists  in  forcible  fracture  of  a  bone.  When  a  bone  is 
partially  united  in  a  faulty  position,  it  may  be  manually  refractured, 
provided  subsequent  reduction  of  the  deformity  seems  attainable.     In 


Fig.  339. —  The  Lower  Opening  in  the  Bone  Is  Made. 

The  second  longitudinal  section  of  bone  is  being  cut  with  the  electrically  driven 
circular  saw. 


all  other  instances,  surgical  attack  upon  bone  should  be  accomplished 
by  the  open  method. 

Operative  Treatment  of  Recent  Fractures. —  The  site  of  a  recent  frac- 
ture is  exposed  for  the  purpose  of  reducing  the  deformity  (when  this 
is  not  attainable  hy  manipulation,  etc.)  and  to  maintain  reposition 
(when  immobilization  of  the  fragments  cannot  be  accomplished  by 
posture,  splints,  extension,  counterextension,  etc.).  This  is  illustrated 
in  connection  with  fracture  of  the  patella  in  which  often  neither 


OPERATIONS   ON  BONES  AND   JOINTS 


789 


approximation  of  the  fragments  nor  their  retention  in  proper  position 
is  possible. 

Reduction  of  the  deformity  in  fractures  b}'  the  open  method  should 
not  be  undertaken  until  the  ordinary  means  have  been  found  insufS- 
cient ;  on  the  other  hand,  when  the  procedure  is  indicated  the  outcome 
is  usually  extremely  satisfactory.  At  this  time,  a  distinction  may  be 
made  between  exposure  of  the  fracture  for  the  purpose  of  correcting 
malposition  of  the  fragments  and  the  fixation  of  the  fragments  {hy 
means  of  sutures,  wires,  nails,  plates,  transplants,  etc.)  because  they 
cannot  otherwise  he  held  in  apposition.  With  this  clear,  the  surgeon 
often  finds,  after  reduction  of  a  fracture,  that  the  use  of  fixation 
material  is  not  necessary  and  immobilization  may  be  proceeded  with 


Fig.  340. —  The  Longitudinal  Sector  of  Bone  Being  Removed  with  the  Gouge 

AND  Mallet. 

as  in  the  closed  method.  This  should  be  done  whenever  possible,  as 
the  trauma  to  the  bone  involved  in  the  introduction  of  fixation  material 
of  any  kind  (including  a  transplant)  is  object  ion  able;  its  presence 
(with  the  exception  of  a  transplant)  interferes  with  repair. 

The  open  reduction  of  a  fracture  is  best  undertaken  one  week 
after  the  occurence  of  the  injury.  After  preliminaiy  exsanguination 
of  the  part  the  fracture  is  exposed ;  the  conditions  which  interfere  with 
reposition  by  manipulation  (such  as  the  incarceration  of  soft  parts) 
are  corrected ;  and  the  fragments  are  forced  into  place  by  means  of 
periosteal  elevators,  bone  hooks,  forceps  (Fig.  332),  or  other  instru- 
ments. These  manipulations  are  carried  out  in  accord  with  the 
diiections  stated  in  connection  with  plates  (p.  799). 


790    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


When  the  deformity  does  not  show  a  tendency  to  recur,  the  sutures  are  intro- 
duced into  the  soft  parts  and  left  untied,  the  wound  is  temporarily  covered 
with  a  protective  dressing  and  the  part  immobilized  by  an  assistant  in  such  a 
manner  as  to  leave  the  wound  accessible.  The  operative  field  is  again  made 
sterile,  the  surgeon  exposes  the  seat  of  the  fracture  and,  if  the  fragments  have 
remained  in  the  desired  position,  a  silkworm  gut  drain  (Fig.  50)  is  intro- 
duced, the  sutures  are  tied  and  the  wound  dressed.  The  drain  is  removed  on 
the  fourth  day  and  the  lesion  treated  as  a  simple  fracture. 

The  operative  fixation  of  recent  fractures  is  employed  when 
open  reduction  does  not  accomplish  the  purpose.  A  number  of  sub- 
stances are  used  and  are  introduced  in  an 
almost  equal  number  of  ways.  Many  of  these 
have  gone  into  history ;  some  of  those  used  at  this 
writing  should  go. 

The  ideal  fixation  material  should  be  suf- 
ficiently strong  to  hold  the  fragments  in  place, 
and  should  be  readily  obtainable.  It  should  be 
susceptible  to  conformation  to  a  given  problem 
without  the  need  of  apparatus  difficult  to  obtain 
or  difficult  to  manage;  it  should  be  possible  to 
place  it  in  situ  with  a  minimum  of  trauma  to  the 
injured  bone;  it  should  not  interfere  with  the 
deposit  of  callus  nor  cause  its  overproduction ; 
and  it  should  be  absorbed  at  about  the  time  the 
fracture  has  united.  Although  this  material  is 
not  yet  available,  of  those  that  are,  each  may  be 
used  under  conditions  which  lessen  its  objection- 
able features  so  that  a  favorable  outcome  is  pos- 
sible, provided  a  proper  selection  is  made  to  meet 
the  special  indications. 

Suturing  of  hone  with  ahsorhaWe  suture 
material  (heavy  chromic  gut,  kangaroo  tendon) 
is  ideal  in  principle;  unfortunately,  its  lack 
of  tensile  strength  greatly  limits  its  field  of 
usefulness.  Material  of  this  sort  may  be  used 
in  place  of  wire  for  holding  in  apposition  the  fragments  in  fractures 
of  small  bones  (such  as  the  metacarpal  and  metatarsal  bones)  when 
there  is  not  much  tendency  to  recurrence  of  malposition.  The  technic 
of  its  application  is  similar  to  that  described  in  connection  with  the 
wiring  of  bone  (p.  792). 

In  the  operative  repair  of  recent  fractures  of  the  patella  the  use  of 


riG.   341. —  Hollowing 

Out    the   Diaphysis 
OF  THE  Humerus. 

The  burr  is  inclined 
first  to  one  and  then  to 
the  other  side. 


OPERATIONS  ON  BONES  AND  JOINTS 


(91 


absorbable  suture  material  has  displaced  the  older  methods  of  drilling 
and  wiring. 

Repair  of  the  patella  hy  suture  involves  opening  the  knee  joint. 
Infection  in  this  situation  is  followed  by  such  serious  consequences  that 
the  reader  is  warned  that,  unless  rigid  asepsis  is  available,  the  opera- 
tion should  not  be  attempted. 

The  surgical  repair  shoujd  not  be  undertaken  until  the  sixth  day 
after  the  injury;  in  the  meantime,  the  limb  is  immobilized  upon  a 
posterior  splint  and  maintained  in  the  elevated  position.     During  this 

time  the  quadriceps 
muscle  may  be  mas- 
saged toward  the 
patella ;  the  joint 
must  be  left  undis- 
turbed. 

A  vertical  incision 
about  five  inches  in 
length,  the  middle 
of  which  corresponds 
to  the  normal  center 
of  the  patella,  is 
made  through  the 
skin  and  subcutan- 
eous tissues  down  to 
the  anterior  apon- 
eurotic prolongation 
of  the  quadriceps 
tendon.  The  skin 
and  subcutaneous 
tissues  are  dissected 
back  with  the  knife, 
and  the  wound  is  held  open  with  retractors,  exposing  the  fracture  and 
the  torn  quadriceps  tendon  (shreds  of  which  overhang  the  ends  of  the 
fragments) ,  and  the  patellar  ligament.  Fluid  blood  and  clots  are  gently 
removed  with  wipes  (do  not  irrigate  the  joint),  including  the  layer  of 
coagulated  blood  covering  the  edges  of  the  fragTnents.  The  sheds  are 
grasped  with  forceps  and  trimmed  off,  level  with  the  bone,  with  sharp 
scissors.  A  kangaroo  tendon  suture  is  passed  above  the  upper  frag- 
ment and  a  second  one  about  the  lower,  as  shown  in  Fig.  342.  The 
sutures  are  now  tied  on  either  side,  bringing  the  fragments  together. 


Fig.  342. —  Suturing  of  a  Fractured  Patella. 


The  kangaroo  tendon  sutures  are  placed  and  ready  to 
be  tied  to  either  side  of  the  patella,  thus  apposing  the 
fragments. 


792     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  toru  aponeurosis  is  repaired  with  a  layer  of  No,  2  chromic  gut 
sutures,  care  being  taken  to  appose  the  torn  aponeurosis  on  either  side 
of  the  patella.  The  superficial  wound  is  closed  with  interrupted 
silkworm  gut  sutures  or  with  silk.  Neither  the  joint  nor  the 
superficial  wound  is  drained.  The  wound  is  dressed  with  a  liberal 
layer  of  sterile  fabric,  and  the  limb  at  once  encased  in  a  gj'psum 
dressing  extending  from  the  upper  portion  of  the  thigh  to  the  base 
of  the  toes. 

The  after  treatment  is  of  great  importance.  The  linib  is  elevated 
immediately  after  the  operation  and  kept  so,  in  order  to  prevent  ten- 
sion on  the  quadriceps  tendon.  On  the  eighth  day  after  the  operation 
a  window  is  cut  into  the  gypsum  cast,  the  wound  is  exposed  and  the 
sutures  are  removed.  At  this  time,  and  daily  thereafter,  the  patella 
(as  a  whole)  is  moved  laterally  to  prevent  its  adherence  to  the  con- 
dyles. When  the  latter  happens  refracture  is  likely  to  occur  when  the 
knee  is  flexed.  On  the  fourteenth  day  the  gypsum  cast  is  removed,  the 
limb  is  bathed,  and  a  light  removable  g>"psum  cast  is  applied.  This 
is  removed  ever}-  day,  the  limb  is  massaged,  paying  especial  attention 
to  the  quadriceps  muscle  (p.  791),  and  careful  passive  motion  of  the 
knee  joint  is  begun.     Full  restoration  of  the  range  of  motion 

SHOULD  BE  attained  AT  THE  END  OF  THE  SIXTH  WEEK  FOLLOWING  THE 

OPERATION.  Complete  return  of  stability  and  power  in  the  limb  is  not 
likely  to  be  attained  (p.  756). 

Wiring  of  recent  fractures  is  employed  in  instances  in  which  fixation 
of  the  fragments  in  the  corrected  position  requires  the  use  of  material 
of  considerable  tensile  strength.  It  is,  of  course,  a  foreign  body  which 
is  a  theoretical  objection  to  its  use.  Its  introduction  is  often  easy, 
it  is  readily  sterilized  and  does  not  cause  great  irritation.  Its  greatest 
field  of  usefulness  is  in  oblique  fractures;  in  the  transverse  it  does 
not  prevent  recurrence  of  the  deformity  as  well  as  other  material, 
such  as  the  Lane  plate ;  however,  the  points  in  its  favor  argue  for  its 
use  in  preference  to  the  plate  when  its  introduction  accomplishes  the 
desired  end. 

For  the  purpose,  silver  wire  has  been  largely  used  which,  to  meet 
the  indications,  must  be  rather  thick,  and  this  means  consider- 
able trauma  to  the  bone.  For  this  reason  it  has  been  discarded  by 
most  surgeons  in  favor  of  gold  plated  copper  wire  which  has  great 
tensile  strength,  is  very  thin  (about  the  thickness  of  florist's  wire), 
and  may  be  introduced  through  a  small  drill  hole.     For  the  fixation 


OPERATIONS   ON  BONES   AND   JOINTS 


793 


of  large  bones  (femur  and  humerus),  several  strands  may  be  twisted 
upon  one  another. 

In  order  to  introduce  the  wire,  the  fragments  are  drillid  -wiih  as 
slender  a  drill  as  will  permit  of  the  passage  of  the  wire.  Drilling  the 
hone  (Fig.  343)  is  best  accomplished  with  a  carpenter's  brace  fitted 


Fig.  343. — -Drilling  the  Bone. 


Fig.  344. —  Doyen's  Trepan  &  Cliquet,  Fitted  with  a  "Chuck"  Which  Holds 

THE  Drill. 

with  a  ''chuck"  which  permits  of  the  use  of  drills  of  various  diameters. 
The  Doyen-  trepan  a  cliquet  fitted  with  a  "chuck"  (Fig.  344)  serves 
the  purpose  very  well.  However,  the  market  is  replete  with  this  sort 
of  thing  and  no  doubt  every  operator  has  a  notion  of  his  own  in  this 
connection.     An  associate  of  the  writer  buys  a  new  carpenter's  brace 


,94    INJURIES  TO  SOFT  PAETS,  BONES  AND  JOINTS 


OP  AN  Oblique  Fracture. 


OPERATIONS  ON  BONES  AND  JOINTS 


795 


for  each  operation,  on  the  ground  that  more  than  one  boiling  causes 
the  mechanism  to  stick  unless  it  gets  better  care  than  is  available  in  an 
operating  room. 

After  the  fragments  are  apposed  by  manipulation  or  with  the  aid  of 
specially  constructed  instruments  in  which  the  technic  of  Lane^ 
(p.  799)  is  closely  followed,  the  drill  holes  are  made  and  the  ware 
introduced  and  twisted  taut.  Fig.  345  shows  various  methods  of 
wiring.  In  (a)  the  wire  is  carried  around  the  bone  at  the  point  of 
greatest  tendency  to  separation;   the  bone  should  be  notched  at  the 


Fig.  346. —  Eontgexograii  of  Wired  Upper  Ulna. 


seat  of  application  to  prevent  the  slipping  of  the  wire.  In  (b)  the 
fragments  are  encircled  by  two  loops  of  wire  held  in  place  by  longi- 
tudinal loops.  In  (c)  two  holes  are  drilled  at  right  angles  to  the  long 
axis  of  the  bone  and  the  ends  of  the  looped  wire  passed  through 
them  (1)  ;  the  loop  is  drawn  to  the  opposite  side  of  the  bone  (2)  ;  the 
loose  ends  of  the  wire  are  carried  around  the  bone  and  fixed  as  shown 
in  (3).  A  silkworm  gut  drain  (Fig.  50)  is  introduced,  the  wound 
sutured  and  the  part  immobilized  as  in  simple  fracture.  On  the 
fourth  day  the  drain  is  removed.  In  most  instances,  it  ultimately 
becomes  necessary  to  remove  the  wire.     For  the  purpose,  the  wire  is 


796    INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 


exposed  through  the  area  of  the  fir^t  incision,  the  loop  is  cut,  the 
twisted  portion  is  grasped  with  suitable  forceps  and  the  wire  is 
withdrawn. 

Nails  and  staples  are  used  for  the  purpose  of  fixing  certain  fractures 
inaccessible  to  other  methods.  The  former  (nailing)  is  an  old  method 
of  fixation  credited  to  Koenig*  who  used  it  for  the  purpose  of  fixing  a 
comminuted  fracture  of  the  neck  of  the  femur  (gunshot)  inflicted 
during  the  "Franco-German  War." 

In  the  fixation  of  recent  fractures  hij  nailing,  the  fragments  are  not 
always  exposed  by  incision ;  this  is  one  of  the  advantages  claimed  for 
the  method.  The  special  indication  for  using  it  lies  in  fractures 
involving  joints  in  which  the  displacement  cannot  be  maintained  in 
correction,  and  the  fracture  is  inaccessible  to  other  means  of  fixation. 
A  description  of  the  method  as  applied  to  fixation  of  the  fragments  in 
fracture  of  the  neck  of  the  femur  may  be  made  to  apply  to  other  bones 
of  the  bod}'.  The  actual  introduction  of  the  nail  or  nails  is  no  differ- 
ent when  the  fracture  is  exposed,  although  in 
most  instances  of  this  kind,  fixation  by  suture, 
wiring,  plating,  etc.,  is  preferable. 

Nailing  the  neck  of  the  femur  without  ex- 
posure of  the  fracture  is  accomplished  as 
follows:  A  small  incision  is  made  over  the 
outer  side  of  the  trochanter  major,  and  an 
assistant  makes  traction  on  the  limb  until 
its  length  corresponds  to  that  of  the  opposite  one.  Remembering 
that,  normally,  the  tip  of  the  greater  trochanter  is  opposite  the  middle 
of  the  head  of  the  femur,  the  bone  is  drilled  to  a  depth  of  four  inches 
in  the  direction  of  the  latter,  the  drill  is  withdrawn  and  the  nail  (4"  in 
length)  is  driven  into  the  drill  canal  by  means  of  a  mallet ;  the  head 
of  the  nail  is  left  protruding  from  the  wound  and  the  limb  is  encased 
in  gypsum  for  six  w-eeks.  The  nail  is  removed  at  the  end  of  this  time. 
In  other  regards  the  treatment  is  that  of  a  simple  fracture. 

The  nail  has  repeatedly  failed  to  transfix  the  fragments  as  desired; 
for  this  reason  Cheyne'^  in  a  case  of  recent  fracture  exposed  the 
■fragments  through  a  longitudinal  incision  made  over  the  anterior 
aspect  of  the  joint;  an  assistant  made  traction  on  the  limb  until  the 
surgeon's  hand  in  the  wound  recognized  that  reposition  of  the  frag- 
ments was  attained.  The  latter  then  proceeded  as  above,  so  that  the 
nail  transfixed  the  fragments  under  guidance  of  the  hand.  The  nail- 
ing method  is  much  practiced  to-day,  not  alone  in  connection  with 


Fig.  347. —  Bone  Staple. 


OPERATIONS  ON  BONES  AND  JOINTS 


797 


fractures  of  the  neck  of  the  femur,  but  also  for  the  purpose  of  fixing 
fractures  of  the  tubercles  and  the  neck  of  the  humerus,  its  condyles, 
the  olecranon,  the  tihia  at  its  lower  end,  and  avulsion  fractures, 
especially  those  of  the  os  calcis,  etc.  In  fractures  of  the  shafts  of  long 
bones,  where  wide  exposure  of  the  fragments  is  feasible,  the  method  is 
not  often  used.     Freeman  V  collection  of  cases  is  worthy  of  study. 

Steel  staples  (Fig.  347)  are  used  in  the  same  class  of  recent  frac- 
tures as  nails,  where  recurrence  of  the  deformity  may  be  obviated 


Fig.  3-48. —  A,  Phantom  of  Fracture  and  Partial  Epiphyseal  Separation  at 
Lower  End  of  Femur.     B,  A  Held  in  Place  with  Staples. 


without  transfixion  of  the  fragments,  such  as  fracture  of  the  neck  of 
the  humerus,  the  lower  end  of  the  femur  in  children  (epiphyseal 
separation),  of  a  single  malleolus,  etc. 

After  reposition  of  the  fragments  is  accomplished,  the  staple  is 
driven  into  place  with  a  mallet  and  the  wound  closed.  At  times 
several  staples  are  used.  Drainage  is  only  employed  when  the  reduc- 
tion has  involved  much  trauma  to  the  soft  parts.  The  after  treatment 
is  similar  to  that  employed  in  connection  with  wiring.  The  staple 
is   easily   removed   after  repair  has  taken   place.     It  is  important 


798     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

that  this  be  done.  Lane^  says  that  "  neglect  to  remove  controlling 
apparatus  results  in  a  cessation  of  growth  over  the  area  of  the  growing 
line  that  is  affected. ' ' 

Fixation  of  recent  fractures  with  Lane's  plates  is  now  an  established 
method  of  procedure.  It  is  not  improbable  that  the  objections  raised 
against  the  plate  were  the  result  of  not  recognizing  the  class  of  cases 
in  which  its  use  is  indicated,  failure  to  master  the  technic  of  applica- 


B 


'M 


t^^Ss 


B 


Fig.  349. —  A,  Mayo-Ociisner  Hemostatic  Forceps.     B.  C,  D,  Elevators  for 
Manipulating  the  Boxe  Fragments. 

tion,  and  failure  to  remove  it  after  union  had  taten  place.     In  recent 

FRACTURES  OF  THE  SHAFTS  OF  LONG  BONES  ATTENDED  WITH  DEFORMITY 
NOT  AMENABLE  TO  CORRECTION  BY  SPLINTS,  EXTENTION,  ETC.,  THERE  IS 
NOT  ANYTHING  MORE  SATISFACTORY  THAN  THE  LaNE  PLATE,  WHEN  THE 

FACTORS  STATED  ARE  TAKEN  INTO  ACCOUNT.  In  Ununited  fractures  the 
transplant  probably  serves  the  purpose  better  (p.  802).    Absorbable 


J 


OPERATIONS  ON  BONES  AND  JOINTS 


799 


suture  material,  wire,  nails  or  staples  may  be  introduced  into  the  bone 
with  less  trauma  and  subsequently  give  rise  to  less  irritation  than  does 
the  Lane  plate ;  however,  none  of  them  holds  the  fragments  as  firmly 
and  as  certainly  as  the  latter.  This  would  seem  to  reduce  the  special 
indication  to  fractures  of  large  bones  (humerus,  femur,  and  tibia)  in 
which  the  deformity  is  subject  to  great  muscular  tension.  The  tecJmic 
of  introducing  the  plate  is  comparatively  simple.  Any  surgeon  who 
has  "fished"  for  the  end  of  a  wire  in  the  bloody  recesses  of  a  deep 
wound  will  agree  with  this.  It  is  not  always  feasible  to  deliver  the 
ends  of  both  fragments  out  of  the  wound  and,  in  recent  fractures,  this 
should  be  avoided. 

The  tecJinic  of  fixing  the  fragments  as  given  by  Lane^  is,  in  sub- 
stance, as  follows:     Apart  from  the  manual  dexterity,  success   in 


Fig.   3."0. —  BoxE  Holding   Forceps  Used  to   Keep  the   Fragments   Apposed 
While  the  Plate  Is  Fastened  in  Place. 


the  operation  depends  upon  the  most  rigid  asepsis.  To  guarantee 
success,  the  surgeon  must  not  touch  the  interior  of  the  wound,  even 
with  the  gloved  hand,  as  gloves  are  very  likely  to  be  punctured  by  com- 
ing in  contact  with  bone.  The  operator  must  not  let  any  portion  of 
an  instrument  which  has  been  in  contact  with  a  cutaneous  surface,  or 
even  with  his  glove,  enter  the  wound.  Instruments  must  be  resteril- 
ized  during  the  operation.  No  germicide  or  other  fluid  should  be 
introduced  into  the  wound.  The  skin  is  prepared  with  ether  or  ben- 
zine, and  tincture  of  iodin  is  applied  immediately  before  the  operation. 
The  incision  should  involve  a  minimum  risk  of  damage  to  important 
structures  and  a  maximum  advantage  from  the  point  of  view  of  acces- 


800    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


sibility  to  the  seat  of  fracture.  A  small  incision  does  not  give  free 
access  to  the  fragments.  A  lengthy  one  in  no  wa}'  increases  the  risks 
and,  as  it  is  less  severely  traumatized  in  the  manipulations,  is  more 
likely  to  heal  primarily.  The  deep  fascia  and  muscles  are  divided 
freely   and   the   fragments   are    fully    exposed.     The    periosteum   is 


Fig,  351. —  Forceps  Used  to  Place  the  Plate  in  Position. 

stripped  from  the  bone  with  the  other  soft  parts.  The  nature  of  the 
fracture  is  determined  and  all  clots  removed.  Arterial  hemorrhage 
is  controlled  by  the  so-called  Mayo-Ochsner  forceps  (Fig.  349A). 
These  are  left  in  place  until  the  end  of  the  operation,  when  they  are 
removed.  Ligatures  are  not  used,  so  as  to  avoid  introducing  the  hand 
into  the  wound.  Elevators  of  various  sorts  and  sizes  are  employed  for 
the  purpose  of  manipulating  the  fragments  into  place  (Fig.  349B,  C, 
D).  The  hone  holding  forceps  used  to  keep  the  fragments  in  position 
while  the  plate  is 
being  fixed  into 
place  is  shown 
in  Fig.  350;  the 
Lowmann  forceps 
shown  in  Fig.  332 
are  very  useful  in 
this  connection.   A 

suitalle  plate  is  chosen  and  held  in  place  by  forceps  (Fig.  351). 
Fig.  352  shows  the  form  of  wrench  suitable  for  bending  plates  to  con- 
form to  the  surface  of  the  bone.  The  plate  is  placed  in  situ  by  means 
of  the  forceps  (Fig.  351) .  The  relationship  that  the  plate  bears  to  the 
fracture  is  shown  in  Fig.  355.    Drill  holes  are  made  with  a  drill  cor- 


FiG.  352. —  Wrench  for  Bending  Plate  to  CoNFORii  to 
Surface  of  Bone. 


OPERATIONS  OX  BONES  AND  JOINTS 


801 


responding  in  size  to  the  screw  that  is  to  be  used,  except  that  when 
the  bone  is  softer  than  is  normal,  a  smaller  drill  is  used.  The  screws 
are  the  ordinary  "wood  screws"  except  that  the  thread  is  cut  up  to 
the  head.  This  enables  the  screw  to  hold  the  proximal  layer  of  com- 
pacta  only,  the  screw  not  entering  and  gripping  the  distal  compacta, 
except  in  children.  The  drilling  is  done  with  an  instrument  of  the  sort 
shown  in  Fig.  344;  the  electric  motor  is  unsuitable  for  the  purpose. 
The  screw  is  held  in  a  convenient  holder  (Fig.  353)  and  is  driven  in 
firmly,  u^ing  a  hand  driver  (Fig.  354)  for  the  purpose.  A  silkworm 
gut  drain  is  introduced  and  the  wound  sutured.  The  limb  is  immo- 
bilized as  in  simple  fracture.  Some  surgeons  (including  Lane)  hold 
that  immobilization  of  the  limb  is  unnecessary.  The  writer  advises 
c-gainst  this  as  taking  unnecessary  risks. 

The  dressing  should  be  so  arranged  as  to  permit  of  removal  of  the 
drain  (on  the  fourth  day)  without  endangering  the  repair.  After 
healing  of  the  wound,  the  lesion  is  treated. as  in  simple  fracture,  i.  e., 
the  early  use  of  massage  and  passive  motion  is  indicated.     After  plat- 


FiG.  3o3. —  Lane's   Screw   IIoi-der. 

ing,  tnese  may  perhaps  be  used  early  with  less  risk  than  when  the 

non-operative  and,  indeed,  some  of  the  less  secure  operative  measures 

.are  employed.     The  2)late  is  removed  ichen  hony  Pinion  has  occurred. 

The  use  of  done  transplant  in  recent  fractures  is  the  outcome  of  the 
demand  for  shorter  and  more  efficient  treatment,  a  shorter  period  of 
disability  and  better  functional  results.  The  bone  transplant  corre- 
sponds to  the  "ideal  fixation  agent"  in  all  particulars  except  that  its 
use  requires  special  skill,  and  it  must  be  introduced  under  conditions 
which  obtain  only  in  a  very  small  percentage  of  the  fractures  "the 
world  over. ' '  Albee^  quotes  Hitzrot  as  saying :  ' '  The  most  striking 
eontra-indications  to  an  open  operation  upon  a  broken  bone  are  inex- 
perience on  the  part  of  the  surgeon,  unsuitable  surroundings,  and 
insufficient  equipment. ' ' 

Whatever  may  be  said  of  the  relative  value  of  ''hand  tools"  to  those 
electrically  driven,  in  bone  surgery  as  a  whole,  there  is  no  doubt  that 
the  fashioning  of  the  bone  transplant  is  best  accomplished  by  the 
latter. 


802    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


The  transplant  is  fashioned  after  the  fracture  is  exposed  and  its 
conformation  necessary  to  the  problem  in  hand  decided  upon. 
Whether  the  problem  calls  for  a  medullary,  an  inlay,  or  a  peg  graft ; 
or  whether  the  graft  is  taken  from  one  of  the  fragments  of  the  frac- 
tured bone;  or  whether  the  fracture  is  a  recent  or  an  ununited  one, 
the  technic  is,  in  all  essential  regards,  the  same.  The 
periosteum  is  incised  longitudinally  and  peeled  back  to 
either  side  in  the  form  of  flaps,  exposing  the  bone  which 
is  to  be  removed  for  the  purpose  of  forming  a  gutter 
ill  the  fragment  or  fragments.  If  the  graft  is  to  be 
obtained  from  the  proximal  fragment,  the  periosteum 
on  this  fragment  is  not  disturbed.  In  recent  fractures 
the  graft  material  can  often  be  taken  from  the  frag- 
ments. The  removal  of  the  graft  is  started  by  mak- 
ing parallel  cuts  1/32  to  1/16  inches  deep,  with  the 
twin  saws  adjusted  at  a  suitable  distance  apart,  depend- 
ing upon  the  size  required  for  the  purpose.  When  a 
wedge  shaped  (inlay)  graft  is  to  be  used,  the  parallel 
saw  cuts  are  continued  through  the  cortex  to  the  medul- 
lary cavity  with  the  single  motor  saw  held  at  such  an 
angle  as  to  cause  the  cuts  to  converge  fn  approaching 
the  medullary  cavity.  When  a  peg,  or  medullary  graft 
is  used,  the  twin  saws  finish  the  cuts  into  the  medulla  || 

of  the  bone.  The  ends  of  the  grafts  are  freed  with 
transverse  cuts  made  with  either  a  very  small  motor 
saw  or  a  narrow  chisel.  Fig.  356  shows  the  method  of 
cutting  a  wedge  shaped  (inlay)  graft.  The  method  of 
preventing  a  square  inlay  graft  from  slipping  into  the 
medullary  canal  is  shown  in  Fig.  357. 

There  are  three  methods  in  use  for  the  autoplastic 
repair  of  recent  simple  fractures,  depending  upon  the 
condition  and  location  of  the  fracture. 

The  medullary  transplant  is  applicable  to  fractures 
of  the  shafts  of  long  bones  in  which  there  is  medullary 
canal  on  both  sides  of  the  fracture  for  a  sutficient  dis- 
tance to  allow  it  to  be  received  into  a  natural  bone 
cavity,  and  in  which  the  physical  surroundings  of  the 
fracture  are  such  that  the  graft  can  be  placed  into  the  ^^^•,  354.— 
medullary  canal  w^ithout  material  harm  (Davison^).  Driver. 


I 


OPERATIONS  ON  BONES  AND  JOINTS 


803 


A  medullaiy  transplant  is  obtained  usually  from  the  tibia  or  fibula, 
of  a  sufficient  length  to  give  stability  at  the  site  of  introduction.  Its 
thickness  should  be  such  as  to  make  contact  with  a  considerable  area 
of  the  circumference  of  its  bed,  yet  it  need  not  be  so  tight  as  to  be  in 

danger  of  pressure  necrosis.  The  graft 
should  be  devoid  of  periosteum,  which 
prevents  bone  to  bone  contact  so  neces- 
sar}'  to  the  grafting  process. 

After  the  fragments  are  exposed  (see 
Lane  technic,  p.  799)  blood  clots  and 
other  products  of  the  traumatism  are 
removed  from  the  Aacinity  of  the  frac- 
ture. The  medullary  canal  of  each 
fragment  is  cleared,  with  the  bone 
curette,  of  the  products  of  traumatism. 
After  measurement  of  the  medullary 
canal,  a  transplant  of  proper  propor- 
tions is  obtained  and  fitted  to  one  frag- 
ment, so  that  it  will  easily  slip  into  the 
canal.  The  latter  is  prepared  by  scrap- 
ing it  out  with  a  reamer  or  a  cylindro- 
spherical  burr  (p.  787)  of  the  same 
size  as  the  graft. 

After  fitting  the  transplant  in  this 
manner  to  the  proximal  fragment,  the 
other  fragment  is  brought  into  the  field 
of  operation  and  the  transplant  fitted 
and  driven  one  half  of  its  length  into 
the  medullary  canal.  The  distal  part 
of  the  extremity,  with  the  transplant 
projecting  from  its  fragment,  is  placed 
at  an  angle  to  the  proximal  part  of  the 
extremity.  The  lower  fragment  is  then 
sharply  retracted  and  manipulated  so 
as  to  enter  the  transplant  into  the 
upper  fragment,  which  is  then  swung  into  proper  alignment  with  the 
remainder  of  the  limb  (Fig.  358). 

Under  favorable  conditions  the  transplant  becomes  a  living  inte- 
gral part  of  the  repaired  hone.  It  takes  part  in  the  functional  support 
of  the  extremity;   for  a  time,  it  maintains  its  size  and  shape;   later. 


Fig.  355.  —  Eoxtgexogram  of 
Fracture  of  the  Shaft  of 
THE  Femur  Fixed  by  a  Lane 
Plate  (Luckett). 


804     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


these,  like  the  other  parts  of  the  skeleton,  are  modified  by  the  con- 
ditions and  functional  demands  upon  it.     It  remains  as  long  as  its 


Fig.  356. —  Methods  of  Obtaining  Wedge  Shaped  Grafts  fkom  the  Tibia. 
(Eedrawn  from  Albee's  ''Bone  Graft  Surgery.") 

support  is  required  and 
then  the  superfluous  part 
is  absorbed  and  the  medul- 
lary canal  reestablished 
(Davison  and  Smith^). 

The  peg  transplant  has 
its  field  of  usefulness  in 
fractures  of  the  ends  of 
long  bones,   where  there  Fig. 

is    no    medullary    canal 
/■p.      .        gv  Illustrates  the  manner  of  fixation  by  means  of 

^^uavison  ).  kangaroo    tendon    passed    through    drill    holes    at 

After  the  area  of  frac-   either    side    of    the    gutter.      One    suture    passes 


357. —  Diagram  of  a  Cross  Section  of 
Graft  Inlaid  in  a  Long  Bone. 


the 


through  the  drill  holes,  loops  over  the  graft,  and  is 


ture  is  exposea,  l  n  c  ^^^^ .  ^-^^  other  passes  under  the  graft  and  through 
space  the  transplant  must,  the  same  drill  holes,  thus  preventing  the  graft 
1     .  ,        .  1       m       from  falling  into   the  medullary  cavity   (redrawn 

bridge  IS  measured.      The   f^om  Albee's  "Bone  Graft  Surgery"). 

transplant     is     obtained, 

without  periosteum,  from  the  tibia,  fibula  or  ulna  (Fig.  356),  in  accord 
with  the  measurement  taken,  and  is  shaped  by  the  dowel  cutter.  The 
malposition  of  the  fragments  is  reduced  and  a  canal  cut,  with  a  reamer 


OPERATIONS  ON  BONES  AND  JOINTS 


805 


or  a  cylindrospherical  burr,  across  the  line  of  fracture.  The  size  of 
the  canal  in  the  fragments  must  correspond  closely  to  that  of  the 
transplant  so  that  correction  of  the  deformity  will  be  maintained. 
When  in  position,  the  transplant  will  be  in  contact  with  both  the 
compact  bone  of  the  corticalis  and  the  cancellous  bone  (Fig.  359). 

The  peg  transplant  holds  the  frag- 
ments in  apposition  and  lives  under 
the  same  conditions  as  the  medul- 
lary. The  portion  of  the  graft 
buried  in  cancellous  bone  stimulates 
the  production  of  osteoblasts,  and 
the  new  bone  increases  in  strength 
according  to  the  functional  demands 
made  upon  it.  Later,  it  is  modified 
and  absorbed. 

The  inkiij  transplant,  which  orig- 
inated with  Albee,^  is  obtained  from 
the  fractured  bone  by  taking  a  seg- 
ment of  unequal  length  from  each 
fragment  and  reversing  the  position 
of  the  long  segment  in  the  gutter,  so 
that  it  will  span  the  line  of  fracture 
(Fig.  360) .  The  method  of  prepara- 
tion for  obtaining  the  inlay  is 
already  described  (p.  803).  The 
application  of  the  inlay  transplant 
is  restricted  to  long  bones  with  an 
even,  fairly  straight,  flat  surface ;  it 
should  be  from  18  to  20  cm.  in 
length,  two  thirds  of  which  must  be 
on  one  side  of  the  fracture  and  one 
third  on  the  other.  The  transplant 
lives,  grafts  to  the  adjacent  bone 
and  becomes  an  integral  part  of  the 
host  under  the  same  conditions  as  obtain  in  connection  with  the  medul- 
lary graft. 

Irrespective  of  the  kind  of  graft  used,  the  wound  is  drained  with 
silkworm  gut  (Fig.  50),  and  closed  by  suture,  and  the  limb  immohi- 
lized,  usually  in  gypsum.     The  drain  is  removed  on  the  fourth  day. 


Fig.  358. —  Preparation  Showing 
THE  Introduction  of  a  Medul- 
lary Transplant  in  a  Eecenx 
Fracture  of  the  Femur. 


806     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

At  the  end  of  the  second  week  the  limb  is  treated  as  in  simple  frac- 
ture.   Massage  and  passive  motion  must  not  he  omitted. 

The  Operative  Treatment  of  TJnunited  Fractures. —  The  operative 
technic  of  ununited  fractures  has  been  made  the  object  of  intensive 
study  in  the  last  decade.  The  causation  and  the  general  considerations, 
are  taken  up  on  p.  649.  At  this  time,  the  reader  is  admonished  that  the 
most  skillful  local  treatment  is  of  little  avail  when  an  underlying 
constitutional  factor  is  not  given  proper  consideration ;  of  these,  lues 
is  not  the  least  important. 

The  requirements  necessary  to  produce  hony  union  are:  (1)  Removal  of 
the  sclerosed  eburnated  bone;  (a)  fixation  of  the  fragments  in  normal  align- 
ment; (3)  stimulation  of  osteogenesis  in  the  region  of  the  ununited  fracture. 


Fig.  359. —  Preparation  op  a  Peg  Transplant  op  the  Neck  op  the  Femur. 


It  would  seem  to  have  been  shown  that  the  introduction  of  metal  or 
other  foreign  body  as  a  material  of  fixation  does  not  serve  as  useful  a 
purpose  as  a  transplant.  Considerable  evidence  has  been  submitted 
tending  to  show  that  the  former  retards  osteogenesis.  The  transplant 
stimulates  osteogensis,  provoking  the  production  of  bony  callus  in  and 
around  the  ununited  fracture.  After  solidification  of  the  fracture  the 
transplant  and  callus  are  absorbed  and  the  new  bone  attains  a  condi- 
tion according  to  requirements. 

In  all  instances,  the  ends  of  the  fragments  are  cleared  of 
interfering  fibrous  tissue  and  refreshed  with  as  little  destruc- 


OPERATIONS  ON  BONES  AND  JOINTS 


807 


V//) 


TiON  OF  BONE  AS  POSSIBLE.  This  Step  is  the  only  one  in  which  the  technic 
of  fixation  differs  from  that  described  in  connection  with  the  use  of  the 
transplant  fixation  in  recent  fractures  (p.  802).  In  addition  to  the 
three  methods  {medullary,  peg,  and  inlay  tra^isplants)  already  de- 
scribed (p.  802),  a  fourth  —  the  contact  transplant  —  is  used 
(Murphy"). 
The  contact  method  consists  in  the  grafting  of  a  segment  of  fresh 

bone  across  the  area  of 
nonunion  to  the  cortical 
surface  of  each  frag- 
ment beneath  the  peri- 
osteum. It  is  applicable 
where  the  fragments  are 
very  small  or  where  ex- 
tensive destruction  of 
the  fragments  has  re- 
sulted from  the  injury'. 
It  is  especially  useful 
where  extensive  rarefi- 
cation  and  absorption  of 
the  fragments  have  oc- 
curred, and  when  these 
are  widely  separated, 
pointed,  and  have  under- 
gone regressive  changes 
(Fig.  361).  The  trans- 
plant introduces  the  nec- 
essarj'  osteogenetic  stim- 
ulus to  provoke  the 
growth  of  new  bone. 

The  technic  of  contact 
grafting  is  not  difiicult. 
The  site  of  the  non-union 
is  exposed,  the  perios- 
teum is  divided  longi- 
tudinally and  reflected  from  the  area  to  which  the  transplant  is  to  b^ 
applied.  A  flat  transplant  is  obtained  in  the  manner  described  (p. 
799),  It  is  fashioned  of  sufficient  length  to  bridge  the  non-union  and 
to  rest  amply  upon  the  healthy  bone  of  each  fragment.  The  periosteum 
of  the  graft  is  transplanted  wnth  it ;  the  endosteum  is  removed  from 


'i 


m 


Fig.  360. — Preparation 
Showing  the  Inlay 
Transplant, 


Fig.  361. —  Atrophy  of 
THE    Ends    of    the 
Fragments    in    the 
Femur. 


808 


INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


that  portion  of  the  graft  in  contact  with  the  bone;  on  the  rest  of  the 
craft  it  is  left  undisturbed.  The  graft  is  held  in  place  by  suturing  the 
periosteum  over  it.  The  wound  is  treated  as  in  the  other  forms  of 
grafting;  the  after  treatment  is  also  the  same.  The  transplant  grafts 
to  the  fragments  on  either  side  of  the  area  of  non-union  and  grows  ni 
thickness  and  strength. 

Osteotomy— In  a  surgical  sense  the  term  osteotomiJ  is  applied  to  the 
division  of  bone  for  the  relief  of  deformity  dependent  upon  ankyloses 
of  joints,  diseases  of  hone,  fractures  united  in  a  faulty  position,  etc. 
The  bone  may  be  sectioned  through  a  free  incision— the  ojyen  method— 
or  a  small  incision  is  made  and  the  bone  sectioned  through  it— the  so- 
called  subcutaneous  method.  In  either  method  of  approach,  division 
of  the  bone  is  linear  and  may  be  transverse  or  oblique ;  or  a  wedge 
shaped  piece  of  bone  is  remoYed— cuneiform  osteotomy. 

Aside  from  the  instruments  already  described,  an  especially  con- 
structed chisel  called  as  osteotome  (Fig.  362)  is  employed.    A  number 


Fig.  362. —  Osteotomes. 


of  very  ingeniously  constructed  saws  have,  in  previous  times,  been 
used  for  the  purpose.  The  practice  of  to-day,  however,  is,  that  when 
the  saw  is  needed,  the  exposure  of  the  site  of  operation  is  made  suffi- 
ciently large  to  permit  of  the  use  of  the  bone  cutting  instruments 
shown  in  Fig.  332.  In  the  subcutaneous  method  it  is  important  that 
the  osteotome  be  strongly  made,  so  that  there  may  be  no  risk  of  its 
breaking  and  of  a  portion  being  left  embedded  in  the  bone. 

Subcutaneous  division  of  the  femur  is  accomplished  by  exposing  the 
upper  border  of  the  neck  of  the  femur  through  an  incision  extending 
upward  from  the  top  of  the  trochanter,  three  quarters  of  an  inch. 
The  osteotome  is  introduced  before  the  knife  is  withdrawn  and  is 
turned  so  as  to  divide  the  neck  in  its  short  diameter. 

A  few  sharp  blows  of  the  mallet,  followed  by  abduction  of  the  limb, 
fracture  the  bone. 


OPERATIONS  ON  BONES  AND  JOINTS  809 

Intertrochanteric  osteotomy  of  ike  femur  (Volkmann)  consists  in 
making  an  incision  along  the  posterior  border  of  the  greater  trochanter 
and  upper  portion  of  the  shaft  of  the  femur,  about  three  inches  in  , 
length.  The  periosteum  is  opened  and  turned  aside  and  a  wedge 
shaped  section  of  the  bone  is  removed  from  just  below  the  great 
trochanter  (Fig.  363),  using  chisel,  gouge,  or  saw,  or  the  electrically 
driven  motor  saw  (Fig.  356)  for  the  purpose. 

In  suMrockanteric  osteotomy  (Gant)  (Fig.  363),  a  linear  division 
of  the  bone  is  made  in  the  same  manner  as  is  described  above  in  con- 
nection with  section  of  the  neck  of  the  femur.  The  section  is  made 
just  below  the  lesser  trochanter. 

When  the  bone  is  sectioned  by  the  so-called 
subcutaneous  method  the  small  wound  in  the 
soft  parts  is  closed  by  suture.  In  the  open 
method,  the  wound  is  drained  with  a  few 
strands  of  silkworm  gut  and  is  closed  by  suture. 
In  either  event,  the  limb  is  placed  in  the  cor- 
rected position  and  immohUized  in  a  gypsum 
spica.  On  the  fourth  day  a  window  is  cut  in 
the  gypsum  cast  and  the  drain  is  removed.  At 
the  end  of  the  second  week  the  cast  is  removed 
^,    ,.,  and  the  case  treated  as  a  simple  fracture. 

'SiU-.J'  In  ankylosis  of  the  knee  joint  the  deformity 

Q«Q    ^      IT  may  be  overcome  by  supracondyloid  osteotomy 

i  16.        oOo.  —  A.,         \  OLK-         „  *.   ,  ,        ,.  ..  .  rry, 

MANN'S  "Wedge  Shaped   01  either  the  linear  or  cuneiform  variety,     ihe 
Intertrochanteric  Os-    methods  of  procedure  are  in  no  essential  par- 

TEOTOMY.       B,     GaNT'S        .        ^  -.-^  »  ,  i  t     n  ^^ 

Osteotomy,  ticular  difterent  irom  those  employed  tor  tne 

correction  of  the  genu  valgum.. 

Linear  osteotomy  from  the  outer  side  is  made  through  an  incision 
of  sufficient  size  to  admit  the  osteotome  (Fig.  362),  one  finger's  breadth 
above  the  upper  portion  of  the  external  condyle  of  the  femur.  The 
osteotome  is  introduced  and  turned  so  that  its  cutting  edge  corres- 
ponds to  the  transverse  axis  of  the  bone  at  the  point  to  be  divided ; 
the  anterior  two  thirds  of  the  femur  is  divided  and  the  posterior  third 
broken  or  bent.  When  the  bone  is  sectioned  from  the  inner  side,  the 
incision  is  made  half  an  inch  in  front  of  and  parallel  with  the  an- 
terior border  of  the  tendon  of  the  adductor  mangus,  beginning  one 
inch  above  its  insertion.  The  remaining  steps  of  the  operation  are 
similar  to  the  preceding. 

In  cuneiform   osteotomy  the  bone  is  exposed  through  an   incision 


V, 


810    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

of  sufficient  length  to  control  the  dimensions  of  the  section  of  bone  to 
be  removed.  The  operation  can  be  employed  above  or  through  the 
.joint;  the  latter  is  the  better  plan.  The  cuneiform  section  of  bone 
is  removed  with  the  osteotome  (Fig.  362),  or  with  the  circular  motor 
saw  (Fig.  333).  After  the  wound  is  drained  with  silkworm  gut  (Fig. 
50)  and  sutured,  the  limb  is  immobilized  in  gypsum  in  the  corrected 
position.  The  after  treatment  in  both  the  linear  and  cuneiform 
osteotomy  is  similar  to  that  described  in  connection  with  the  femur 
(p.  809). 

OPERATIONS  ON  JOINTS 

In  recent  years  no  department  of  surgery  has  received  more 
fruitful  attention  than  that  accorded  the  surgery  of  the  joints. 
This  has  been  the  direct  outcome  of  the  study  of  the  behavior 
of  transplanted  bone  (p.  801).  In  a  work  of  this  kind,  new 
methods  of  procedure  based  on  a  new  conception  of  the  behavior  of 
living  tissue  must  be  carefully  considered  before  it  is  permissible  to 
present  the  subject  to  the  younger  members  of  the  profession ;  more 
especially  as,  in  this  instance,  the  presentation  calls  for  a  terminology 
which  involves  discarding  some  of  the  older  terms  and  the  employment 
of  others  destined  to  convey  an  adequate  notion  of  the  subject. 

The  primary  subdivisions  of  the  subject  relate  first,  to  the  approach, 
i.  e.,  the  exposure  of  the  joint  surfaces;  second,  to  the  various  methods 
of  dealing  with  the  conditions  found  within  the  joint,  these  being: 
modified  to  meet  the  problem  as  presented  when  the  exposure  is  made. 

The  method  of  approach  is  modified  in  accord  with  the  intent,  that 
is  to  say,  the  avenue  of  approach  should  conform  to  the  character  and 
extent  of  the  process  to  M-hich  measures  of  relief  are  addressed.  This 
may  be  illustrated  as  follows :  Given  an  intra-articular  lesion  of  the 
knee  joint,  limited  to  a  semilmiar  cartilage,  it  would  be  manifestly 
unnecessary  to  section  the  patella  and  M'idely  expose  the  interior  of 
the  joint  cavity,  when  a  comparatively  restricted  curved  incision  over 
either  the  inner  or  the  outer  aspect  of  the  joint  permits  of  re- 
moval of  the  offending  agent.  Per  contra,  when  the  surgical  prob- 
lem involves  removal  of  a  chronically  thickened  synovia,  together 
with  more  or  less  of  the  articular  surfaces  of  the  bones,  any  other 
exposure  than  a  wide  one  would  not  meet  the  indications. 

The  term  arthrocentesis  is  employed  for  aspiration  of  a  joint; 
when  a  joint  is  opened  for  drainage  or  for  other  purposes,  the  term 
arthrotomy  is  used. 


OPERATIONS  ON  BONES  AND  JOINTS  811 

It  is  proposed  to  discontinue  the  terms  excision,  resection,  and 
erasion,  as  applied  to  distinct  operations,  and  to  employ  in  their  stead 
the  simpler  terms  of  partial  and  complete  arthrectomy.  Da  Costa 
devotes  considerable  effort  to  the  terms  excision,  resection,  erasion,  etc., 
and  makes  the  distinctions  moderately  clear.  However,  an  effort 
to  make  one  of  the  terms  include  all  the  various  steps  of  the  modern 
method  of  dealing  with  the  conditions  found  in  a  given  joint  must,  of 
necessity,  fail.  For  instance,  the  pathological  conditions  in  an  elbow 
joint  may  demand  erasion  of  the  synovia,  resection  of  the  head  of  the 
radius,  and  excision  of  the  articular  surface  of  the  internal  condyle  of 
the  humerus.  Properly,  exposure  of  the  joint  should  be  called  an 
arthrotomy,  and  the  additional  steps  called  an  arthrectomy.  As  the 
latter  is  not  possible  without  the  former,  the  term  partial  arthrectomy 
would  seem  to  be  adequately  descriptive,  yet,  when,  in  accord  with  the 
modern  methods,  a  fascial  fat  flap  is  introduced  into  the  joint  the 
term  artroplasty  is  used,  and,  when  the  joint  is  caused  to  ankylose,  the 
term  arthrodesis  is  used. 

In  discussing  the  subject  of  operations  upon  joints,  the  technic  of 
arthroceniesis,  arthrotomy,  partial  and  complete  arthrectomy  and 
arthrodesis  will  be  taken  up  in  connection  with  each  of  the  joints  in 
which  any  of  the  above  are  employed.  In  addition  to  this,  the  method 
of  approach  best  suited  to  the  intent  will  be  indicated.  In  connection 
with  arthoplasty,  measures  which  tend  to  obviate  habitual  dislocation 
in  certain  joints  have  to  be  taken  into  account. 

To  summarize : 

Arthroceniesis — aspiration  of  a  joint. 

Arthrotomy — opening  of  a  joint  for  drainage,  removal  of  foreign 
body,  etc.    (including  corpus  mobile). 

Arthrectomy — (partial  or  complete)  removal  of  pathological 
synovia,  ligaments,  articular  surfaces,  portions  of  the  contiguous 
bones,  exudates  and  tumors. 

Arthroplasty — reestablishment  of  the  function  of  the  joint  by  the 
introduction  of  soft  parts  after  arthrectomy,  and  the  correction  of 
various  pathological  conditions,  including  the  prevention  of  habitual 
luxation. 

Arthrodesis — fixation  of  a  joint. 

Arthrocentesis. — Arthrocentesis,  or  aspiration  of  a  joint,  is  employed 
for  the  purpose  of  removing  fluid  exudate,  i.  e.,  serum,  pus,  fluid 
blood.    The  measure  is  not  employed  as  often  as  it  should  be  for  the 


812     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

purpose  of  removiDg  large  quantities  of  blood  from  the  joint  in  cases 
of  intra-articular  fracture. 

The  technic  of  the  procedure  calls  for  the  exercise  of  strict  asepsis. 
The  skin  over  the  entire  joint  is  cleansed  and  painted  with  iodin.  As 
a  rule,  a  combined  aspirator  and  injector  is  used.  Fig.  364  presents 
a  simple  mechanism  suitable  for  the  purpose.  It  is  proper  to  say,  how- 
ever, that  at  this  time  the  intra-articular  injection  of  medicinal  agents 
is  rarely  used,  except,  perhaps,  in  joint  tuberculosis  (p.  467). 

Arthrotomy. — Arthrotomy  alone,  as  already  stated,  is  employed  for 
the  purpose  of  drai^iing  a  joint  or  for  the  removal  of  a  foreign  body, 
including  joint  mice.  When  a  portion  of  the  joint  substance  (such 
as  a  piece  of  cartilage)  is  removed,  it  may,  perhaps,  be  more  consis- 
tent to  employ  the  term  partial  arthrectomy.    However,  this  is  "split- 


Fiu.  364. —  Combined  Aspirator  and  Injector. 


ting  hairs"  and  calls  for  unnecessarily  fine  distinctions.  The  technic 
of  arthrotomy  is  taken  up  in  connection  with  the  surgery  of  the  various 
joints.  At  this  time,  we  may  say  that  its  performance  does  not  call 
for  the  use  of  special  instruments. 

The  technic  of  partial  and  complete  arthrectomy,  arthroplasty,  and 
arthrodesis  is  also  taken  up  with  the  surgery  of  the  various  joints. 
However,  in  this  class  of  operations  special  instruments  are  used.  Most 
of  these  are  already  taken  up  in  connection  with  the  surgery  of  the 
bones  and  are  shown  in  Figs.  332  and  333 ;  additional  instruments 
will  be  described  in  the  discussion  of  operative  efforts  of  relief  di- 
rected to  the  special  joints. 

The  Temporomaxillary  Joint. — In  arthrocentesis  of  the  temporomaxil- 
lary  joint  the  needle  is  entered  one  quarter  of  an  inch  in  front  of  the 


OPERATIONS  ON  BONES  AND  JOINTS 


813 


tragus  and  the  same  distance  below  the  lower  border  of  the  zygoma, 
a  point  corresponding  to  about  the  lower  end  of  the  transverse  portion 
of  the  incision  shown  in  Fig.  365.  The  measure  is  employed  for  diag- 
nostic  purposes. 

In  arihrotomij,  i.  e.,  opening  of  the  joint  for  drainage,  the  joint  is 
exposed  by  means  of  an  incision  one  inch  in  length  and  corresponding 
to  the  perpendicular  portion  of  the  incision  employed  for  arthrectomy 
and   arthrotomy    (Fig.    365)  ;   this  is   described   in  connection  with 


Fig.  365. — •  The  Temporomaxillary  Joint,  Showing  the  Internal  Maxillary 
Artery,  Facial  Ner\"e,  and  the  Location  of  the  Incision  for  Arthrectomy 
(Heudersou  and  New  in  Surgery,  Gynecology,  and  Obstetrics). 

arthrectomy.  The  distended  capsule  is  punctured  with  the  blunt  point 
of  a  small  forcipressure  and  a  drain  consisting  of  several  strands  of 
silkworm  gut  is  placed  in  situ.  The  earhj  active  use  of  the  joint  tends 
to  prevent  ankylosis. 

Arthrectomy  applied  to  the  temporomaxillary  joint  consists  prac- 
tically of  the  excision  of  the  head  of  the  condyle;  when  a  fascial  or  a 
fat  transplant  is  employed,  the  operation  may  be  called  an  arthro- 
plasty.   On  the  ground  that  motion  in  the  joint  is  aimed  at,  Henderson 


814    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


and  New"  call  the  operation  an  arthroplasty  irrespective  of  the  use  of 
the  transplant. 

The  incision  (Fig.  365)  is  curved  and  about  two  inches  in  length. 
Its  anterior  and  upper  portion  runs  one  half  inch  above  and  parallel 
to  the  zygoma.  The  posterior  arm  extends  downward  just  in  front 
of  the  tragus  to  about  the  level  of  the  floor  of  the  external  auditory 
canal.  The  antero-inferior  skin  flap  is  partially  dissected  free  in 
order  to  expose  the 
zygoma.  An  in- 
cision parallel  to  the 
zygoma  and  directly 
over  it  is  made  and 
the  temporal  fascia 
is  retracted  idown- 
ward,  exposing  the 
zygoma  and  the  joint 
region.  The  entire 
flap  is  then  turned 
downward  and  for- 
ward, carrying  with 
it,  and  holding  out 
of  the  way  of  in- 
jury, the  temporo- 
facial  nerve.  The 
wound  is  held  open 
by  a  self  retaining 
mastoid  retractor 
placed  obliquely  in  yig. 
the  wound  (Fig. 
366).  The  portion 
of  the  zygoma  di- 
rectly over  the  joint 

area  is  removed  with  a  small  rongeur  or  a  gouge,  leaving  the  upper 
portion  of  the  bone  intact  to  maintain  the  contour  of  the  face.  This 
exposes  the  condjde  which  can  be  removed  with  the  gouge.  The 
latter  step  must  be  carefully  executed.  Electrically  driven  instruments 
are  not  suitable  for  the  purpose.  Enough  of  the  bone  and  the  inflam- 
matory deposits  must  be  removed  to  allow  of  free  motion.  As  it  is  not 
necessary  to  place  fascia,  fat  or  other  membrane  between  the  end  of  the 
mandible  and  the  temporal  bone,  the  operation,  in  a  narrow  sense, 


366. —  The    Wound    Held    Open    with 
Eetaining  Mastoid  Eetractor. 


A    Self 


The  lower  portion  of  the  zygoma  is  removed,  a  rim  of 
bone  being  left  above.  The  condyle  is  removed  (Hender- 
son and  New  in  Surgery,  Gynecology,  and  Obstetrics). 


OPERATIONS  ON  BONES  AND  JOINTS  815 

is  not  an  arthroplasty.  The  cavity  is  drained  as  in  arthrotomy  and 
the  wound  closed  by  means  of  interrupted  horsehair  sutures.  The 
dram  is  removed  on  the  fourth  and  the  sutures  on  the  sixth  day  fol- 
lowing the  operation.  The  operation  may  be  carried  out  on  both 
sides  at  the  same  sitting. 

On  the  day  following  the  operation,  and  on  each  succeeding  day, 
the  mouth  is  forced  open  until  there  is  no  tendency  to  return  of  the 
ankylosis. 

Arthrodesis  of  the  temporomaxillary  joint  is  not  done. 

The  Shoulder  Joint. — The  indications  for  arthrocentesis  of  the 
shoulder  joint  are  the  same  as  are  taken  up  in  connection  with  arthro- 
centesis generally  (p.  811). 

The  technic  is  simple.  After  preparation  of  the  skin,  the  needle 
is  made  to  enter  the  distended  capsule  through  the  upper  end  of  the 
deltoid  muscle  a  finger's  breadth  below  the  tip  of  the  acromion  process 
(Fig.  367). 

The  term  arthrotomy,  used  in  connection  with  the  shoulder  joint, 
applies  to  its  drainage  and  its  exposure  for  various  purposes. 

For  drainage,  an  incision  (Fig.  367)  is  made  over  the  anterior  sur- 
face of  the  joint  (attributed  to  v.  Langenbeck^-),  beginning  at  the 
anterior  edge  of  the  acromion  process  and  extending  downward  about 
two  and  one  half  inches;  the  fibers  of  the  deltoid  are  separated,  ex- 
posing the  capsule  of  the  joint.  This  is  opened  with  the  scissors ;  the 
exudate  is  evacuated  and  the  scissore  carried  on  past  the  outer 
side  of  the  neck  of  the  humerus  and  caused  to  perforate  the  soft  parts 
behind.  A  suitable  forceps  is  guided  by  the  slowly  receding  scissors 
from  behind  and,  upon  its  appearance  in  front,  is  caused  to  draw  a 
quarter  inch  fenestrated  rubber  drainage  tube  (Fig.  48)  back  and 
out  through  the  posterior  opening.  The  toilet  of  the  anterior  wound  is 
made ;  the  soft  parts  are  approximated  by  means  of  two  deeply  placed 
silkworm  gut  sutures  and  the  protective  dressing  is  applied.  The 
drainage  tube  is  removed  as  soon  as  the  discharge  from  the  joint 
ceases.     Early  passive  motion  is  employed. 

For  the  purpose  of  more  extensive  intra-articular  manipulations, 
such  as  the  open  method  of  treating  irreducible  dislocations  of  the 
head  of  the  humerus,  for  partial  and  complete  arthrectomj^,  for  arthro- 
plasty and  for  arthrodesis,  a  slightly  different  incision  (attributed 
to  Ollier^^)  is  made. 

This  begins  at  the  base  of  the  coracoid  process  and  on  a  level  with 
it,  and  extends  downward  (Fig.  367)  three  and  one  half  inches  to  four 


816     INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 


inches  through  the  skiu  and  the  fascia;  the  space  between  the  pecto- 
ralis  major  and  the  deltoid  muscles  is  found  and  the  muscles  are 
separated  (avoiding  the  cephalic  vein). 

When  employed  for  irreducihie  luxation  of  the  head  of  the  humerus, 
this  is  exposed  and  either  the  luxation  is  reduced  or  excision  of  the 
head  of  the  bone  is  practiced. 


Fig.  367. —  Phantom  of  Shoulder  Joint. 

1,  Needle  introduced  for  arthroeentesis.       2.  Langenbeek 's  incision. 
incision.     4.  U-shaped  incision. 


3.  Oilier 's 


As  is  the  case  with  most  writers,  the  presentation  of  this  subject 
is  based  on  the  remarkable  monograph  of  Edward  Souchon^*  of  New 
Orleans,  who  tells  us  that  operative  relief  in  this  class  of  cases  dates 
back  to  Weinhold  and  Swanzig  (1819)  and  scintillated  through 
Dieffenbach  (1839),  Simon  (1852),  our  own  Post  (1861),  the  luminous 
Langenbeek    (1870),  Delbet    (1893),  McBurney    (1895),   and  other, 


OPERATIONS  ON  BONES  AND  JOINTS  817 

perhaps,  lesser  lights,  all  of  which  he  has  chranologically  arranged  in 
the  work  mentioned,  to  which  the  reader  is  referred  for  additional 
information  in  this  connection  (see  Bibliography). 

Reduction  of  the  luxation  is  desirable  but  not  always  attainable.  It 
is  permissible  when  the  head  of  the  bone  and  the  glenoid  cavity  is  in 
good  condition ;  when  no  extensive  dissections  have  to  be  made ;  when 
it  is  easily  effected ;  when  the  head  does  not  have  to  be  trimmed  or  the 
cup  to  be  deeply  scooped  or  enlarged ;  when  the  head  readily  remains 
in  place,  but  not  too  tightly.  Removal  of  the  head  of  the  bone  should 
be  practiced  in  all  other  cases  (see  below). 

Souchon's  work  shows  that,  among  the  difficulties  and  complications 
which  may  be  expected  during  the  operation,  the  chief  ones  are :  A 
much  thickened  capsule  or  much  fibrous  tissue  around  the  head  of  the 
bone,  necessitating  a  tedious  dissection  with  persistent  bleeding.  The 
head  may  lie  very  deep  and  may  he  adherent  to  the  adjacent  parts, 
e.  g.,  the  ribs,  and  the  deeper  the  position  the  greater  are  the  difficulties 
of  the  operation.  When  thus  firmly  fixed,  the  head  may  be  prized  into 
its  natural  position  by  means  of  elevators,  scoops,  bone  hooks,  etc. 
(Fig.  332),  and  this  failing,  division  of  the  bone  and  its  piecemeal 
removal  may  be  necessary.  The  glenoid  cavity  may  be  so  filled  as  to 
need  refashioning.  The  axillary  vessels  and  nerves  ma}'  lie  across  the 
head  of  the  bone. 

The  COMBIXATION  OF  FRACTURE  OF  THE  UPPER  PART  OF  THE  HUMERUS 
AND  THE  LUXATION  OF  ITS  HEAD  PRESENTS  A  DIFFICULT  PROBLEM.      In  the 

absence  of  the  leverage  of  the  arm,  reduction  of  the  luxation  is  at- 
tended Avith  great  difficulty.  The  lesion  is  exposed  as  above  (Fig. 
367)  and  a  McBurney^^  traction  hook  is  inserted  into  the  lower  end  of 
the  upper  fragment  (Fig.  368).  This  often  makes  reduction  possible 
The  fracture  may  he  fixed  at  the  same  sitting.  For  the  purpose,  the 
medullary  transplant  (p.  802)  would  seem  to  offer  the  best  promise. 
This  is  especially  indicated,  as  prompt  union  permits  of  the  early  use 
of  massage  and  passive  motion.  The  wound  is  drained  and  sutured 
as  in  arthrotomy  for  drainage  only.  The  after  treatment  is  also 
similar. 

For  relief  of  habitual  luxations  the  capsule  is  made  smaller  or,  when 
this  does  not  accomplish  the  purpose,  arthrodesis  or  excision  of  the 
head  of  the  bone  is  performed.  In  either  event,  the  joint  is  exposed 
through  an  anterior  incision — that  of  Oilier  (Fig.  367). 

Plication  of  the  capsule  (Ricard^^)  is  a  simple  procedure.  The 
upper  end  of  Oilier 's  incision  is  prolonged  at  right  angles,  following 


818     INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 

the  contour  of  the  insertion  of  the  deltoid,  to  the  clavicle  and  the 
acromion;  the  muscle  is  detached  and  turned  outward  and  back- 
ward ;  the  coracobranchialis  is  lifted  by  an  assistant ;  the  operator 
frees  the  upper,  or  inferior,  edge  of  the  subcapular  muscle  at  its 
humeral  insertion ;  the  arm  is  rotated  inward  so  that  the  anterior  wall 


Fig.  368. —  McBurney's  Traction  Hook  for  the  Ekduction  of  Fractures 
AND  Dislocated  Bones. 


of  the  capsule  is  relieved  of  tension,  then,  through  the  top  of  this 
wall,  through  the  capsule,  and  into  the  thickness  of  the  subscapularis 
muscle,  the  operator  passes  three  stitches  of  heavy  silk,  vertically  di- 
rected and  about  two  cm.  one  from  the  other.  The  free  extremities 
of  these  threads  are  tied  in  order  to  reduce  this  anterior  wall  to  the 
least,  but  most  resistant,  and  rigid  thickness.  This  is  the  ideal  opera- 
tion for  habitual  dislocations  (Souchon^*).  Gerster^'^  and  BurrelP^ 
resect  a  portion  of  the  capsule  and  approximate  it  by  suture. 

In  arthrodesis  of  the  shoulder  joint  the  exposure  is  made  as  in 
arthrotomy  (see  above)  and  the  head  of  the  bone  is  delivered  through 
the  wound  as  in  arthrectomy  (see  below).  The  cartilage  of  the  glen- 
oid fossa  and  acromion  process  and  that  of  the  surface  of  the  head 
of  the  humerus  is  removed ;  the  humeral  head  is  placed  in  the  glenoid 
cup  and  a  bone  graft  peg  (p.  804)  is  inserted  into  it  through  the 
acromion  process.  Drainage,  suture  and  after  treatment  as  in  arthro- 
tomy (p.  815). 

In  artlirectomy,  the  exposure  is  made  as- in  arthrotomj^  (p.  815). 
After  the  deltoid  and  pectoralis  major  muscles  are  separated,  the 
biceps  tendon  is  located  and  the  capsule  divided  at  its  outer  side  from 
below  upward ;  the  borders  of  the  wound  are  drawn  apart  and  the 
soft  parts  separated  from  the  upper  and  outer  surface  of  the  bone, 
by  means  of  the  periosteal  elevator  or  other  suitable  instrument,  as 


OPERATIONS  OX  BOXES  AND  JOIXTS 


819 


the  bone  is  slowly  rotated  inward ;  the  muscles  inserted  into  the  greater 
tuberosity  are  divided  at  their  insertions;  the  humerus  is  rotated  out- 
ward and  the  inner  aspect  of  its  head  cleaned  in  the  same  way ;  the 
lesser  tuberosity'  is  located ;  the  insertion  of  the  subscapularis  is  separ- 
ated and  the  capsule  beyond  is  divided ;  the  tendon  of  the  biceps  is  dis- 
placed inward  and  the  head  of  the  bone  delivered  through  the  wound 
hy  carrying  the  elbow  backward  and  upward   (Fig.  369)  ;  as  much 

of  the  head  of  the 
bone  is  removed  as 
is  necessary  to  meet 
the  conditions.  For 
the  purpose,  the 
Gigli-Hiirtel  saw,  a 
hand  saw,  chisel  and 
mallet  (Fig.  332), 
or  the  electrically 
driven  circular  saw 
(Fig.  333)  may  be 
used.  The  glenoid 
cavity  is  cleaned 
with  the  spoon, 
gouge  or  burr. 

The  head  of  the 
bone  may  be  re- 
moved without  de- 
livering it  through 
the  wound.  Most 
surgeons,  however, 
prefer  the  former 
method.  During  the 
manipulations,  the 
circumflex  nerve 
must  be  avoided.  Care  must  be  taken  that  no  sharp  spicula  of  bone 
are  left  attached  to  the  bone. 

The  residual  joint  cavity  is  drained  as  in  arthrotomy  (p.  815)  ;  the 
wound  closed  by  suture  and  the  protective  dressing  applied.  Passive 
motion  is  begun  on  the  eighth  day  following  the  operation. 

The  U-shaped  deltoid  flap  (Fig.  367)  gives  ample  room  but  leaves 
a  large  scar  and  is  followed  by  almost  total  impairment  of  deltoid 


Fig.    369. —  The   Head   of   the   Humerus    Deliyeeed 
Through  the  Anterior  Arthrotomy  Wound. 

The  Gigli-Hartel  saw  in  place  ready  to  section  the 
bone  from  behiml. 


820     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


power   (Longmore^'').     Partial  arthrectomy  is  followed  by  ankylosis 
unless  supplemented  by  arthroplasty. 

Arthroplasty  at  the  shoulder  joint  does  not  occupy  a  prominent 
place  in  the  literature.  This  is  probably  due  to  the  fact  that  partial 
excision  of  the  head  of  the  humerus,  even  w^hen  followed  by  a  certain 
degree  of  ankylosis,  does  not  seriously  interfere  with  function  because 
of  the  movements  of  the  arm  made  possible  by  the  motilitj^  of  the 
scapula.  The  technic  of  the  procedure  is  similar  to  that  described  in 
connection  with  arthrectomy  and  arthrotomy,  including  delivery  of 
the  head  of  the  humerus  through  the  wound. 
At  this  time,  the  latter  may  be  subjected  to 
decortication  of  the  cartilage  and  replaced.  A 
flap  consisting  of  fascia  and  fat  may  be  dis- 
sected from  the  anterior  pectoral  region  and 
"tucked  in"  between  the  caput  and  the  pan; 
or  a  free  transplant  consisting  of  fascia  lata 
and  fat  may  be  taken  from  the  thigh  and  in- 
serted into  the  joint  in  a  similar  manner.  As 
already  stated,  data  in  this  connection  are  not 
available  at  this  time.  The  after  treatment 
should  be  similar  to  that  following  arthrectomy. 

The  Elbow  Joint. —  Arthrocentesis  of  the 
elbow  joint  is  employed  for  diagnostic  purposes 
and  for  the  removal  of  hloody  exudate  in  con- 
nection with  intra-articular  fractures.  The 
skin  is  painted  with  iodin  and  the  needle  of  the 
aspirator  (Fig.  364)  entered  one  quarter  of  an 
inch  above  the  tip  of  the  olecranon  (with  the 
forearm  flexed  at  right  angles).  In  this  way 
the  tendon  of  the  triceps  muscle  is  transfixed  ; 
however,  puncture  of  the  capsule  at  either  side  vision; 

„  •         1  IT  p    •     •  ,       cision; 

or  m  front  involves  the  danger  ot  injury  to  lateral  incisions, 
important  nerves  and  vessels. 

Arthrotomy,  in  the  sense  of  opening  the  elbow  joint  for  drainage, 
for  partial  or  complete  arthrectomy,  or  for  arthroplasty,  may  be  done 
by  means  of  three  incisions  (Fig.  370).  That  is  to  say,  it  may  be 
accomplished  in  the  following  way:  In  artlirotom]}  for  drainage  it  is 
best  to  employ  the  two  lateral  incisions,  on  the  ground  that  thus  egress 
of  the  exudate  from  all  parts  of  the  capsule  is  favored.  Partial  arth- 
rectomy may  be  achieved  through  either  of  the  lateral  incisions  alone; 


Fig. 


370. —  Phantom   of 
Elbow  Joint. 

Langenbeck  's      in- 

b,  Oilier 's     in- 

c,  c,    ^Vlurphy  's 


OPERATIONS  OX  BOXES  AXD  JOIXTS  821 

complete  arthrectomy  aud  arthroplasty  may  be  accomplished  by  em- 
ploying both  lateral  incisions  at  one  time,  while  complete  arthrectomy 
with  removal  of  the  articular  ends  of  the  three  bones  entering  into  the 
formation  of  the  elbow  joint  may  be  performed  through  the  single 
posterior  incision — a  method  most  often  used  for  extensive  disease 
in  this  situation.  Jacobson-"  seems  inclined  to  advise  the  employment 
of  radical  measures  (complete  arthrectomy)  through  the  posterior 
incision. 

After  the  joint  is  opened  by  means  of  the  two  lateral  incisions  for 
simple  drainage,  a  small  rubber  tube  (Fig.  48),  a  strip  of  iodoform 
gauze  or  a  hank  of  silkworm  gut  (Fig.  50)  is  passed  through  the 
joint,  a  protective  dressing  is  applied  and  the  limb  immobilized  in 
semiflexion.  The  drain  is  left  ;'.>/  situ  until  the  discharge  of  exudate 
ceases.  The  immobilizing  apparatus  (gypsum  or  wire  splint)  must  be 
arranged  to  permit  of  the  early  employment  of  passive  motion,  the 
effectiveness  of  which  determines  the  degree  of  sequential  ankylosis. 
Persistent  mechanicotherapy  is  of  great  value. 

For  complete  arthrectomy,  with  removal  of  the  articular  ends  of  the 
bones,  the  posterior  vertical  incision  of  Langenbeck-^  (that  of  Oilier" 
may  be  used)  shown  in  Fig.  370  is  most  frequently  employed.  The 
incision  (three  or  four  inches  in  length)  is  made  with  its  center  at  the 
tip  of  the  olecranon,  slightly  internal  to  the  center  of  the  back  of  the 
joint  and  parallel  with  the  ulnar  nerve ;  it  should  go  down  to  the  bone 
throughout  its  entire  extent,  splitting  the  triceps  muscle  and  tendon. 
The  outer  half  of  the  triceps  tendon  and  its  expansion  over  the  fore- 
arm, together  with  the  anconeus,  are  peeled  up  as  thickly  as  possible 
from  the  ulna.  This  is  accomplished  with  a  minimum  of  tearing, 
using  the  knife  or  elevator  for  the  purpose.  The  deeper  parts 
on  the  outer  side  of  the  joint  are  then  separated  from  the  bones  until 
the  external  cond^ie  and  the  head  of  the  radius  are  exposed;  ulti- 
mately, all  of  the  soft  parts  are  turned  aside  over  the  external 
condyle.  X>xt,  the  parts  on  the  inner  side  of  the  joint  are  de- 
tached from  the  inner  condyle  and  the  inner  border  of  the  olecranon, 
great  care  being  taken  not  to  injure  the  ulnar  nerA'e.  This  may  be 
avoided  by  ''hugging  the  bone"  with  the  instrument  used  in  separ- 
ating the  soft  parts.  In  operating  soon  after  injury,  the  nerve  is  in 
danger  of  being  injured;  when  the  joint  has  been  inflamed  for  a 
long  time  the  soft  parts  and  the  embedded  ner^'e  are  easily  pushed 
aside.  Denuding  of  the  bony  prominences  is  facilitated  by  keeping  the 
joint  fully  extended,  thus  relaxing  the  soft  parts.     Each  lateral  liga- 


822     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

ment  is  raised  and,  together  with  the  periosteum  and  the  groups  of 
flexor  or  extensor  muscles,  freed  from  and  pushed  over  the  condyles, 
and  held  there  with  retractors.  The  joint  is  now  strongly  flexed  and 
the  capsule  opened  just  above  the  olecranon,  or  the  olecranon  may  be 
cut  off  with  a  chisel  or  saw  and  access  to  the  joint  be  gained  in  this 
way  (Heath--).    The  ends  of  the  bones  are  turned  out  of  the  wound 


Fig.  371. —  Complete  Arthrectomt  of  Elbow  Joint. 
The  articular  ends  of  the  bones  are  sawed  off. 


and  prepared  for  section.  The  soft  parts  at  the  anterior  aspect  of  the 
joint  are  easily  separated  from  the  bone  with  the  elevator.  This  is 
facilitated  by  preliminary  removal  of  the  olecranon. 

The  site  of  bone  section  is  an  important  consideration.  The  ulna 
should  be  sawed  so  that  the  greater  and  lesser  sigmoid  cavities  are 
removed  with  the  olecranon.    The  head  of  the  radius  is  removed  just 


OPERATIONS  ON  BONES  AND  JOINTS 


823 


above  the  insertion  of  the  biceps.  The  section  of  the  humerus  should 
he  given  special  attention.  In  complete  arthrectomy  the  line  of  sec- 
tion is  made  ''just  above  the  level  of  the  epicondyle  and  through  the 
highest  part  of  the  epitrochlea,  quite  removing  the  lower  two  thirds 
of  this  process.     This  is  the  very  lowest  level  at  which  the  surgeon 


Fig.  372. —  Wire  Splint. 

The  supine  position  of  the  hand  is  well  maintained  by  the  apparatus.     It  may 
be  bent  at  any  angle   (MacCormack). 


Fig.  373. —  Exposure  of  the  Joint  from  the  Radial  Side. 

The  positions  of  the  humerus,  radius  and  ulna  are  indicated  by  dotted  lines. 
Note  the  direction  in  which  the  curved  chisel  is  applied  to  separate  the  bones  on 
the  radial  side  of  the  joint;  also,  that  the  curve  of  the  chisel  employed  for  the 
division  corresponds  to  the  normal  curve  of  the  articular  surface  of  the  elbow 
joint,  tluis  prescrvinjT  its  contour   (from  Murj)hy  Clinics). 


824     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

should  make  the  section  if  he  desires  to  obtain  good  movement" 
(Jacobson-°).  Ollier^^  makes  the  section  slightly  higher.  Any  resid- 
ual involvement  of  the  bones  is  removed  with  the  gouge  or  the  spoon. 
Annadale-^  considers  that  one  and  one  half  inches  should  intervene 
between  them,  when  the  bones  are  extended.  Fig.  371  shows  the  con- 
dition of  affairs  when  the  arthrectomy  is  completed. 

A  drain  consisting  of  silkworm  gut  (Fig.  50),  rubber  tissue  (Fig. 
52),  or  a  rubber  drainage  tube  (Fig.  48)  is  inserted  into  the  wound 
cavity  and  brought  out  at  its  lower  angle.  The  deep  structures  are  ap- 
proximated with  three  interrupted  chromic  gut  sutures  and  the  skin 


Fig.  374. —  The  Ulnar  Xerve  Held  Aside;  the  Condyle  Separated  from  the 
Ulna  ;  the  Articular  End  of  the  Humerus  Is  Being  Cut  Off  with  a  Chisel 
(from  Murphy  Clinics). 

wound  is  closed  with  silkworm  gut.  After  application  of  the  protec- 
tive dressing,  the  arm  is  placed  on  an  angular  wire  splint.  Gypsum 
may  be  used  and  should  be  arranged  so  as  to  allow  of  its  frequent 
removal  and  reapplication.  The  wire  splint  is  readily  sterilized  by 
boiling.  Removal  of  the  drainage  agent  and  the  sutures  is  dependent 
upon  the  discharge  of  wound  secretions.  If  these  are  not  free,  there 
is  no  objection  to  the  removal  of  the  sutures  and  the  drain ;  the  wound 
may  be  lightly  tamponed  with  iodoform  gauze  and  a  secondar}^  repair 
made  at  a  later  time  (p.  13).  The  method  gives  excellent  results. 
The  after  treatment  determines  the  ultimate  outcome.     At  each 


OPERATIONS  OX  BOXES  AXD  JOIXTS 


825 


dressing  the  angle  of  the  splint  is  changed ;  this  suggests  that  a  wire 
splint  (Fig.  372)  be  used.  Massage  of  the  fingers,  lower  forearm,  and 
upper  arm  should  be  begun  on  the  fourth  day  after  the  operation. 
Passive  motion,  other  than  that  incidental  to  change  of  posture  as 
stated,  is  begun  as  soon  as  the  irritation  at  the  site  of  the  operation  has 
subsided.    Mechanicotherapy  is  employed  as  early  as  possible. 

Partial  arthrcctomy  is  preformed  through  either  or  both  of  the 
lateral  incisions  shown  in  Fig.  370.  It  is  probable  that  the  method  is 
indicated  only  in  cases  of  injury  making  removal  of  either  the  head 
of  the  radius  or  of  the  lower  end  of  the  humerus  necessary,    la  cases 


Tig.  375. —  Fl.vp  CoxsiStixg  of  Fascia  axd  Fat  Dissected  Up  from  the  Outer 
Side  of  the  Arm  (from  Murphy  Clinics). 


of  disease  or  of  ankylosis  following  disease,  the  method  is  followed  by 
ankjdosis  in  the  former  instance  and  does  not  relieve  the  latter  condi- 
tion. Under  these  circumstances,  complete  arthrectomy  or  arthro- 
plasty are  the  better  procedures  (Billroth,-*  MacCormac,-'  and  others). 
Stimson,^®  Ollier,^^  and  others  employ  the  lateral  incisions  for  com- 
plete arthrectomy  in  cases  of  ankylosis. 

Arthroplasty,  as  here  described,  is  used  in  cases  of  ankylosis  fol- 
lowing inflammatory  conditions  (such  as  pneumococcus,  typhoid, 
staplndococcus,  gonococcus,  streptococcus  infection,  etc.)  in  which  the 
process  has  healed.    It  is  probably  of  no  value  in  cases  of  injury  and 


826     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


joint  tuberculosis ;  in  these  the  radical  operation  is  more  certain  to  be 
followed  by  a  favorable  outcome. 

Arthroplasty,  a  recent  acquisition  to  the  field  of  surgery,  has  been 
devised  to  take  the  place  of  the  older  operation  of  erasion.  The  latter 
(advocated  by  Glutton^')  soon  fell  into  disfavor  as  the  method  did  not 
provide  for  the  interposition  of  fascial  flaps  and  was  followed  by  return 
of  the  ankylosis.  Although  arthroplasty  is  not,  as  yet,  generally  re- 
garded as  taking  the  place  of  the  older  methods,  it  has  in  many  in- 
stances been  followed  by  such  brilliant  results  that  the  technic  (that 
of  Murphy^^)  is  described  in  detail. 


Fig.  376. —  Innee  Flap  "Tucked"  Into  Place  and  Fastened  to  the  Perios- 
teum OP  the  Bicipital  Fascia. 

The  central  sutures  uniting  the  two  flaps  are,  of  course,  not  shown  (from 
Murphy  Clinics). 

The  joint  is  exposed  by  two  lateral  incisions  (Fig.  370).  O71  the 
radial  side,  the  radius  is  separated  from  the  humerus  by  means  of 
an  especially  constructed  curved  chisel  (Fig.  373).  On  the  ulnar  side 
the  nerve  is  exposed  to  the  full  extent  of  the  incision  and  held  aside 
with  a  gauze  loop  (not  an  instrument)  ;  the  olecranon  is  separated 
from  the  internal  condyle  in  the  same  manner  as  is  the  radius  from 
the  external ;  a  portion  of  the  articular  ends  of  both  condyles  of  the 
humerus  is  removed  with  the  chisel  (Fig.  374).  A  pediculated  fat 
and  fascial  flap  is  dissected  from  the  outer  side  of  the  arm  for  inser- 


OPERATIONS  ON  BONES  AND  JOINTS 


827 


tion  into  the  joint  (Fig.  375).  A  similar  flap  is  dissected  up  from  the 
irmer  side  of  the  forearm.  Each  flap  is  "tucked"  between  the  bones 
from  its  own  side  and  united  in  the  center  by  two  catgut  sutures ;  the 
inner  flap  is  also  sutured  to  the  periosteum  of  the  ulna  and  to  the 

bicipital  fascia  (Fig. 
376)  ;  the  outer  is  held 
in  place  by  suturing  it 
to  the  periosteum  of 
the  humerus.  The 
wounds  are  closed  with- 
out drainage  and  the 
limb  immobilized  as 
after  complete  arthrec- 
tomy.  The  after  treat- 
ment (except  with  re- 
gard to  drainage)  is, 
in  all  essential  particu- 
lars, similar  to  that  fol- 
lowing arthrectomy.  It 
is  imperative  that  mas- 
sage, passive  motion 
and  mechanicotherapy 
be  persistent!}'  and  in- 
telligently employed. 

The  Wrist  Joint.— 
Arthrocentesis  of  the 
wrist  joint  is  employed 
for  diagnostic  purposes 
and  for  the  removal  of 
bloody  exudate  occur- 
ring in  connection  with 


Fig.  377. 


The  Structures  Concerned  in  Arthrec- 
tomy OP  THE  Wrist. 


AA,    BB,    CC,    the    three    incisions    employed    by 
Oilier.     Only  the  two  lateral  are  use  in  arthroplasty 
(Murphy).     D,  Bockel's  incision  sometimes  described 
as  Langenbeck's;    the  two   are  practically  identical; 
R,  radius;  U,  ulna;   1,  2,  radial  extensors  of  carpus;    intra-articular  injuries. 
3,  extensor  ossis  metacarpi  pollicis;   4,  extensor  primi    rp,        .        . 
internodii;  5,  extensor  secundi  internodii;  6,  extensor        ^^  intricate   arrange- 
communis;    7,    extensor   indicis;    8,    extensor    minimi    meilt     of    the     svnovia 
digiti;  9,  extensor  carpi  ulnaris  (Oilier).  ,  ,.  '  . 

and  ligaments  makes  it 

necessary  to  state  that  the  puncture  will  have  to  be  made  over  the  point 

of  greatest  distention,  which  is  usually  over  the  dorsum  of  the  joint. 

It  may  be  necessary  to  make  several  punctures  before  the  desired  end 

is  achieved.    Strict  asepsis  must  be  observed. 

Arthrotomy  for  drainage,  or  for  exposure  of  the  joint  for  partial  or 


828     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

complete  arthrectomy,  is  best  performed  through  Oilier 's  dorsal  and 
radial  incisions  (Fig.  377). 

For  drainage  (pyo-arthrosis),  the  joint  is  opened  (Fig.  377)  on  its 
dorsum,  and  the  exudate  is  permitted  to  escape;  a  dull  scissors  or  a 
slender  forcipressure  is  passed  through  the  joint  and  out  through  an 
incision  made  over  the  internal  lateral  aspect  of  the  joint.  Fig.  377). 
A  silkworm  gut  drain  is  drawn  back  through  the  wound  canal  thus 
made,  and  brought  out  through  the  dorsal  opening;  an  incision  is 
made  over  the  external  lateral  aspect  of  the  joint  and  a  drain  is  in- 
serted as  on  the  inner  side.  A  protective  dressing  is  applied  and  the 
limb  immobilized  on  the  wire  splint  shown  in  Fig.  378.  The  drain 
is  removed  when  the  discharge  of  exudate  ceases.  Passive  motion,  mas- 
sage and  mechanicotherapy  are  begun  as  soon  as  the  irritation  in  the 
joint  has  subsided  (about  two  to  three  weeks). 

Within  reasonable  restrictions,  approach  to  the  wrist  joint  may  be 
varied  in  accord  with  the  lesion  for  which  operative  measures  of  relief 
are  undertaken.  Quite  all  the  aspects  of  the  joint  are  accessible 
through  one  or  all  of  the  three  measures  described  (see  Fig.  377). 
Therefore,  for  convenience,  partial  and  complete  arthrectomy  are  de- 
scribed together..  The  operative  procedure  which  follows  originated 
with  011ier.-« 

The  primary  incision  begins  at  a  point  in  1he  center  of  a  line  drawn 
between  the  two  styloid  processes  and  extends  downward  at  first  ver- 
tically and  then  slightly  obliquely  outward,  and  ends  over  the  second 
metacarpal  bone  at  the  junction  of  its  middle  and  lower  thirds  (Fig. 
377).  This  is  carried  down  to  the  periosteum  and  dorsal  ligaments, 
care  being  taken  to  avoid  injury  to  the  extensor  indicis  and  the  ex- 
tensor carpi  radialis  brevis.  The  extensor  indicis  is  drawn  aside,  ex- 
posing the  tendon  of  the  extensor  carpi  radialis  brevis ;  the  periosteum 
over  the  third  metacarpal  bone  is  opened  and  the  latter  tendon  de- 
tached from  its  insertion,  thus  giving  access  to  the  radial  aspect  of 
the  deeper  structures  of  the  joint.  The  deep  incision  is  then  prolonged 
upward,  in  accord  with  the  pathological  condition  present,  crossing 
the  annular  ligament  outside  the  space  occupied  by  the  extensor  indicis 
and  communis.  Higher  up,  the  incision  passes  between  the  extensor 
indicis  and  the  extensor  secundi  internodii,  these  tendons  being  drawn 
respectively  inward  and  outward.  At  the  central  end  of  the  incision 
the  periosteum  of  the  radius  is  divided.  The  incision  thus  made  is 
about  four  inches  in  length.  The  ulnar  iyicision  begins  about  one 
inch  above  the  styloid  process  and  ends  over  the  base  of  the  fifth  meta- 


OPERATIONS  ON  BONES  AND  JOINTS 


829 


carpal  bone  (Fig.  377)  ;  it  is  made  nearer  the  palmar  surface  so  as  to 
leave  the  tendon  of  the  extensor  carpi  ulnaris  in  the  upper  portion  of 
the  wound.  The  incision  is  deepened  down  to  the  cuneiform  and  unci- 
form. The  third  incisioji,  for  drainage,  is  about  one  inch  long  and 
is  made  over  the  styloid  process  of  the  radius  (Fig.  377). 

Removal  of  the  hones  is  preceded  b^'  sectioning  of  the  posterior  an- 
nular ligament,  which  allows  of  separation  of  the  tendons.  The 
radiocarpal  joint  is  opened;  the  periosteal  and  ligamentous  connec- 
tions of  the  carpus  are  carefully  sectioned,  and  the  carpus  is  gradu- 
ally forced  out  through  the  dorsal  incision  while  the  tendons  are  held 
aside  by  means  of  retractors  (blunt).    The  bones  are  removed  through 


Fig.  378. —  Wike  Splint  for  Artiirectomy  of  Wrist. 

pp,  Support  for  palm  of  hand;  cp,  curved  piece  of  metal  to  separate  thumb 
and  sup])ort  it  in  any  desired  position;  j)h,  wire  supports  for  forearm  and  arm, 
united  by  a  wire,  which  may  be  bent  ad  libitum,  so  that  the  position  of  the  joints 
may  be  changed  at  eacli  dressing. 


either  the  dorsal  or  the  ulnar  incision,  or  through  both.  The  removal 
of  one  bone  facilitates  the  removal  of  another,  and  so  on.  Each  bone 
is  delivered  from  its  embedding  periosteal  and  ligamentous  adhesions 
by  means  of  the  elevator,  curved  blunt  scissors  or  forcipressure.     It  is, 

AT  TIMES,  FEASIBE  TO  LEAVE  THE  TRAPEZIUM  OR  THE  UNCIFORM  PROCESS 
OF  THE  UNCIFORM  ;  THE  ARTHRECTOMY  BEING  THEN   INCOMPLETE.       The 

ends  of  the  radius  and  the  ulna  and  the  diseased  sectors  are  removed, 
using  the  small  circular  saw  (Fig.  333)  for  the  purpose.  As  little  of 
these  bones  as  is  possible  should  be  removed.  The  styloid  processes  are 
preserved,  if  feasible.  Conservation  in  this  connection  is  called 
"modeling  resection"  by  Oilier-'^  and  may  be  regarded  as  an  initial 


830     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

step  in  the  direction  of  modern  arthroplasty.  Portions  of  the  perios- 
teum that  appear  healthy  should  also  be  left  in  situ.  The  operation  is 
a  tedious  one  and  should  be  thoroughly  rehearsed  by  the  surgeon 
before  it  is  undertaken.  In  tuberculous  disease,  the  cautery  has  been 
much  used;  recently,  however,  this  has  been  omitted.  The  residual 
cavity  is  thoroughly  dried  and  drained  in  the  manner  described  in 
connection  with  arthrotomy.  The  superficial  wound  is  closed  with 
silkworm  gut ;  the  protective  dressing  is  applied  and  the  limb  immo- 
hilized  on  the  wire  splint  shown  in  Fig.  378,  which  allows  the  change  of 
posture  of  the  hand  at  each  dressing.    Drainage  is  removed  about  the 


Fig.  379. —  Exposure  of  the  Ulnar  Side  of  the  Wkist  Joint.    L)ivision  of  the 
Ankylosis  with  the  "Artist's  Chisel"  (from  Murphy  Clinics). 

tenth  day.  If  secretion  accumulates  and  distends  the  cavity,  the 
sutures  may  be  removed  and  the  former  lightly  tamponed  with  iodo- 
form gauze.  Secondary  suture  repair  may  be  practiced  as  late  as  the 
third  week.  This  contingency  need  not  interfere  with  the  measures 
advised  in  connection  with  the  after  treatment. 

The  after  treatment :  Massage  of  the  fingers  is  begun  on  the  second 
day  following  the  operation.  The  thumb  and  index  fingers  are  kept 
widely  separated  (Fig.  378).    On  the  eighth  or  tenth  day,  passive 

MOTION  OF  the  WRIST  IS  BEGUN.  ThE  PROMPTNESS,  THOROUGHNESS, 
AND  PERSISTENCE  WITH  WHICH  MECHANOTHERAPY  IS  USED  DETERMINES 


OPERATIONS  ON  BONES  AND  JOINTS  831 

THE  DEGREE  OP  ULTIMATE  FUNCTION  ;    THE  MEASURE  IS  EMPLOYED  AS  SOON 
AS  THE  CONDITION  OF  THE  WOUND  PERMITS. 

Arthroplustij  is  employed  at  the  wrist  joint  for  the  relief  of  anky- 
losis following  healed  inflammatory  processes.  For  the  purpose, 
Murpli}^-*  employs  two  lateral  incisions  (Fig.  377).  The  ulnar  side  of 
the  joint  is  exposed  and  the  ulnocarpal  articulation  separated  by 
means  of  an  ''artist's  chisel,"  the  contour  of  which  conforms  to  the 


«p 

■^ 

H 

■ 

■ 

>^g 

^^^^^^ 

£»«| 

If 

^ 

S^^^^^^Bl^^  ■ 

\ 

-««^  ' 

Fig.  380. —  Pkeparatiox  of  the  Ulnar  Side  of  the  Wrist  for  Introduction  of 
THE  Ulnak  Pedicled  Fat  and  Fascia  Flap. 

Note  that  an  interval  of  about  one  half  an  inch  in  wiclth  has  been  chiseled 
away  between  the  ulna  and  carpus,  the  lower  end  of  the  ulna  being  rounded  off  to 
fit  into  the  proximal  side  of  the  carpus,  which  has  been  correspondingly  hollowed 
out  to  receive  it,  the  normal  architecture  of  the  joint  thus  being  simulated  (from 
Murphy  Clinics). 

ouuine  of  the  normal  articular  surfaces  (Fig.  379)  ;  about  five  eighths 
of  an  inch  of  the  lower  end  of  the  ulna  and  a  rim  of  the  carpus  are 
removed  (Fig.  380)  ;  a  fat  and  fascia  flap  is  dissected  up  from  the 
outer  palmar  region  of  the  wrist  above  the  joint  and  "tucked"  into  the 
chiseled  out  space;  this  is  fastened  to  the  periosteum  of  the  ulna  and 
to  the  subcutaneous  tissue  in  the  manner  shown  in  Fig.  381.  Practi- 
cally, the  same  procedure  is  enacted  on  the  radial  side  of  the  wrist. 
The  two  flaps  are  united  in  the  center  of  the  joint  by  sutures  introduced 
by  means  of  a  needle  holder.  In  some  instances.  Murphy  was  able  to 
remove  sufficient  of  the  bones  through  the  radial  incision,  and  succeeded 
in  interposing  one  large  fat  and  fascia  flap  from  that  side ;   as  a  rule, 


832     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Pig.  381. —  Ulnar  Fl.vp  Turned  Into  the  New  Joint  Cavity  and  Fastened  to 
THE  Periosteum  of  the  Ulna  and  to  the  Subcutaneous  Tissue  by  Means 
OP  Three  Catgut  Sutures  (from  Murphy  Clinics). 

however,  two  incisions  and  two  flaps  are  employed.  The  wounds  are 
closed  without  drainage  and  the  limb  immobilized  m  a  removable 
gypsum  dressing;  or  the  wire  splint  of  Oilier  (Fig.  378)  may  be  used 
for  the  purpose. 

The  after  treat- 
ment is  similar  to 
that  described  in 
connection  with  ar- 
threctomy. 

Arthrodesis    has 
been  employed  for 
the  relief  of  ' '  drop 
wrist"      following 
anterior  poliomye- 
litis.   Fig.  382  pre- 
sents   a    diagram- 
matic illustration  of  the  technic  used  by  Albee.^     The  graft   was 
obtained  from  the  tibia  in  the  manner  described   (p.  804),  inserted 
into  the  radius  above  and  rested  on  the  dorsum  of  the  os  magnum 
below.   The  ultimate  outcome  was  very  satisfactory  (see  Bibliography). 


Fig.  382. —  Illustrating  the  Shape  and  Position  of 
the  Bone  Graft  in  Its  Application  to  Support  a 
Paralytic  Wrist  in  Extension  and  to  Eestore  the 
Grasp  of  the  Flexion  of  the  Fingers  (redraw-n 
from  Albee's  "  Bone  Graft  Surgery  "). 


OPERATIONS  ON  BONES  AND  JOINTS 


833 


The  Hip  Joint. —  Arthrocentesis  of  the  hip  joint  is  employed  for  diag- 
nostic purposes  and  for  the  removal  of  exudate.  After  painting  the 
skin  with  iodin,  the  needle  of  the  aspirator  (Fig.  364)  is  entered  imme- 
diately above  the  tip  of  the  trochanter  and  advanced  toward  the  aceta- 
bulum ;  the  former  is  on 
a  level  with  the  center 
of  the  joint.  The  dis- 
tended capsule  is  readily 
punctured  in  this  way 
without  danger  to  im- 
portant structures  (Fig. 
383). 

Arthrotomij,  consid- 
ered from  the  stand- 
point of  drainage  alone, 
is  best  accomplished  by 
means  of  the  posterior 
incision  (Fig.  383).  As 
this  inci::ion  is  also  em- 
ployed for  arthrectomy, 
and  to  avoid  repetition, 
the  reader  is  referred  to 
its  description  submitted 
in  connection  with  ar- 
threctomy. 

At  this  time,  the  at- 
tention of  the  reader  is 
called  to  the  fact  that, 
practically  all  surgical 
measures  of  relief  (ex- 
cluding arthroplasty  and 
a  rthodesis ) ,  including 
nailing  and  bone  graft- 
ing in  connection  with 
fractures,  are  attainable 
through  one  or  both  of  the  incisions  described  under  the  head  of 
arthrectomy.  It  is  also  desirable  to  note  that  the  simultaneous  employ- 
ment of  both  incisions  is  not  objectionable  when  the  conditions  demand 
it  (see  fractures  of  the  n«?k  of  the  femur,  p.  733). 
After  the  capsule  of  the  joint  is  opened,  which  is  accomplished  by 


Fig.  383a. —  Phaxtom  of  Hip. 
Aspirating     needle     introduced,     and 
incision  for  arthrectomy. 


anterior 


834    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


means  of  blunt  scissors,  a  drainage  tube  may  be  inserted  into 
the  former  and  brought  out  through  the  lower  angle  of  the  wound. 
The  incision  may  be  closed  with  three  deeply  placed  silkworm  gut 
sutures,  leaving  ample  space  between  them  for  the  escape  of  exudate 
which  does  not  find  its  way  out  through  the  tube;  however,  when 
there  is  much  destruction  of  bone  and  an  active  inflammatory  process 
is  present,  tube  drainage  may  be  omitted  and  the  cavity  lightly  tam- 
poned with  iodoform  gauze  and  the  wound  surfaces  apposed  by  suture 
at  a  later  date,  i.  e.,  when  repair  is  distinctly  manifest. 

In  either  event,  a  Buck's  extension  (p.  739)  is  applied  to  the  limb. 
This  is  probably  preferable  to  immediate  immobilization  in  gypsum. 
When  the  process  has  subsided  the  case  is  treated  as  after  arthrectomy. 
The  degree  of  sequential 
ankylosis  is  in  no  small  meas 
ure  dependent  upon  the  as- 
siduous application  of  the 
after  treatment  (see  arthrec- 
tomy, p.  824). 

In  arthrectomy  by  the  pos- 
terior approach  (v.  Langen- 
'beck^^),  an  incision  about 
four  inches  in  length  is  made 
over  the  middle  of  the  troch- 
anter (Fig.  383),  commencing 
about  midway  between  the  tip 
of  the  bone  and  the  posterior 
superior  spine  of  the  ilium 
and  ending  over  the  shaft  below  the  trochanter.  The  incision  should 
be  slightly  curved  (concavity  forward)  and  is  carried  down  to  the  bone 
through  its  entire  length.  A  second  incision  opens  the  capsule  freely. 
The  muscles  attached  to  the  trochanter  are  peeled  ofif  by  means  of  the 
elevator  or  with  a  short  stout  knife.  The  soft  parts,  and  as  much  of 
the  periosteum  as  is  possible,  are  detached  from  the  medio-inferior 
aspect  of  the  neck  of  the  femur.  After  making  certain  that  the  soft 
parts  are  adequately  separated  from  the  bone,  it  is  sectioned  (while 
still  in  situ)  with  a  chisel,  Gigli-Hartel  wire  or  a  circular  saw.  The 
head  of  the  bone  is  pried  out  of  the  acetabulum  by  seizing  the  tro- 
chanter with  the  lion  jaw  forceps.  The  ligamentum  teres,  if  not 
destroyed,  is  forcibly  avulsed;  the  acetabulum,  when  necessary,  is 
scraped  out,  and  sequestra  or  carious  bone  gouged  from  the  shaft 


^^^^^^^^ 


Fig.  383b. —  Phantom  of  Hip. 

Additional  arthrectomy  incisions;  a. 
Langenbeck's  incision;  h,  Sayre's  in- 
cision ;  G,  Murphy 's  incision. 


OPERATIONS  ON  BONES  AND  JOINTS 


835 


of  the  femur.  AVhen  a  drainage  tube  is  inserted  into  the  residual 
cavity,  it  is  permitted  to  protrude  from  the  lower  angle  of  the  wound 
and  the  surfaces  of  the  latter  apposed  with  a  few  deeply  placed  silk- 
worm gut  sutures,  or  the  wound  is  lightly  tamponed  with  iodoform 
gauze.     The  tampon  is  changed  daily  until  repair  is  clearly  manifest, 


Fig.  384. —  Arthroplasty  of  the  Hip  Joint. 

The  flap  of  skin,  fat  and  fascia  lata  has  been  dissected  up  and  is  retracted 
upward;  the  wound  is  held  open  with  retractors.  Bj'  means  of  a  curved  needle 
a  chain  saw  is  passed  underneath  the  superior  muscle  group  —  chiefly  the  gluteus 
medius  —  down  to  the  capsule  of  the  joint,  and  the  trochanter,  with  the  muscles 
attached,  is  sawed  off  in  the  direction  indicated  by  the  dotted  line  (from  Murphy 
Clinics). 


when  secondary  suture  repair  may  be  made.  The  latter  is  a  good 
plan.  In  other  regards  the  after  treatment  is  the  same  as  is  used  after 
arthrectomy  by  the  anterior  incision. 

The  anterior  incision  (Fig.  383A),  generally  credited  to  Barker,^" 
though  it  originated  with  Hiiter,^^  is  four  inches  in  length,  begins 
half  an  inch  below  the  anterosuperior  spine  of  the  ilium  and  extends 


836     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

downward  and  slightly  inward  toward  the  medial  side  of  the  tensor 
vaginae  femoris  muscle.  The  upper  portion  of  the  incision  exposes 
the  capsule  at  once,  the  lower  extends  through  the  skin  only.  The 
muscles  are  drawn  apart  and  the  capsule  opened  and  entirely  sep- 
arated from  its  attachment  to  the  head  and  neck  jof  the  bone  by 
means  of  elevators,  blunt  scissors,   etc.     This  is  not  always  easily 


Fig.  385. —  Arthroplasty  op  the  Hip  Joint. 

The  trochanter,  with  its  attached  muscles,  is  drawn  upward,  the  anterior  fibers 
of  the  gluteus  medius  having  been  cut.  The  capsule  of  the  joint  is  being  incised 
at  right  angles  to  the  direction  of  its  fibers.  In  this  operation  it  is  not  necessary 
to  cut  either  the  pyriformis  or  obturator  externus  muscles  (from  Alurphy  Clinics). 


accomplished.  The  neck  of  the  bone,  close  to  the  trochanter,  is  sec- 
tioned with  the  chisel  or  a  Gigli-Hartel  saw ;  the  head  of  the  bone  is 
grasped  with  lion  jaw  forceps  and  "twisted"  out  of  the  acetabulum, 
which  is  treated  as  stated  immediately  above.  The  method  is  prop- 
erly applicable  to  cases  in  which  the  pathological  process  is  limited  in 
extent.  After  the  diseased  bone  has  been  removed  the  cavity  is 
drained  with  textile  fabric    (iodoform  gauze  or  a  cigarette  drain, 


OPERATIONS  ON  BONES  AND  JOINTS  837 

and  the  wound  closed  with  silkworm  gut;  or  the  wound  cavity 
is  lightly  tamponed  with  iodoform  gauze  and  secondary  suture  repair 
of  the  soft  parts  made  later  (p.  68).  In  the  latter  method,  the 
tampon  is  changed  daily.  Finally",  a  Buck's  extension  apparatus 
(p.  739)  is  applied  to  the  limb  until  repair  is  established,  when  a 
gypsum  imn)ol)i1izi]Tq'  dressing  may  be  used. 


Fig.  386. —  Arthroplasty  op  the  Hip  Joixt. 

The  large  gougs  is  being  driven  between  the  head  of  the  femur  and  the 
acetabulum,  to  divide  the  bouy  ankylosis  between  the  two.  Xote  that  a  gouge  has 
been  selected,  the  cruve  of  which  is  that  of  the  normal  head  of  the  femur  and 
the  acetabulum,  so  that  a  minimum  amount  of  reshaping  is  necessary  after  division 
of  the  ankylosis  (from  Murphy  Clinics). 

The  after  treatment  consists  in  the  use  of  apparatus  which  allows 
the  patient  to  leave  the  bed  as  early  as  possible.  Of  the  many  devised 
for  the  purpose,  the  Thomas  splint  is  used  by  most  surgeons. 
Massage  and  passive  motion  of  the  lower  portions  of  the  limb,  knee 
and  ankle  are  employed  while  the  patient  is  still  in  bed.  Later,  these 
are  the  main  factors  whicli  determine  the  outcome.     They  are  espe- 


SSg     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

cially  necessary,  as  the  patient  should  not  walk  on  the  affected  limb 
(without  support)  for  a  long  time  (about  one  year),  with  the  view  of 
preventing  an  undue  degree  of  shortening. 

Arthroplasty  in  connection  with  the  hip  joint  is  employed  for  the 
relief  of  ankylosis  following  the  healing  of  inflammator}^  processes  in 
this  situation.  The  technic  has  been  developed  by  Murphj^"*-  A 
goblet  shaped  incision,  which  is  shown  in  Fig.  383,  is  made  at  the 


Fig.  387. —  Arthroplasty  of  the  Hip  Joint. 

Keshaping  the  head   of  the  femur  and   the   acetabular   cavity    (from   Murphy 
Clinics). 

lateral  aspect  of  the  region  of  the  hip.  After  a  flap  consisting  of 
skin,  subcutaneous  tissue  and  fascia  lata  is  dissected  up,  the  tro- 
chanter is  sawed  off  as  indicated  in  Fig.  384,  using  a  chain  saw 
or  Gigli-Hartel  for  the  purpose  (Albee^  uses  the  circular  motor  saw). 
The  trochanter,  with  its  muscles  attached,  is  drawn  upward,  the 
gluteus  medius  having  been  cut,  and  the  capsule  of  the  joint  is  incised 
as  shown  in  Fig.  385.     After  separating  the  adhesions,  the  head  of 


J 


OPERATIONS  ON  BONES  AND  JOINTS 


839 


the  bone  is  separated  from  the  acetabulum  by  means  of  a  large,  espe- 
cially constructed  gouge,  in  the  manner  shown  in  Fig.  386.  The  head 
of  the  bone  is  delivered  over  the  posterior  lip  of  the  wound  and  it, 
together  with  the  acetabulum,  is  reshaped  with  "end  mill  reamers" 
as  shown  in  Fig.  387.  A  pedicled  fascia  and  fat  flap  is  dissected  from 
the  under  surface  of  the  upper  flap,  the  trochanteric  muscle  flap  is 


Fig.  388. —  Arthroplasty  of  the  Hip  Joint. 

A  fascia  and  fat  flap  has  been  dissected  from  the  upper  skin  flap,  rotated  around 
the  trochanter  muscle  flap,  turned  down  into  the  refashioned  acetabulum,  and 
fastened  to  its  rim  by  means  of  four  chromic  gut  sutures  (from  Murphy  Clinics). 


held  aside  and  the  former  is  turned  down  over  and  into  the  refash- 
ioned acetabulum  and  fastened  to  its  edge  with  four  chromic  gut 
sutures  (Fig.  388).  The  head  of  the  bone  is  placed  in  the  newly 
cushioned  acetabulum;  the  trochanteric  muscle  flap  is  dropped  into 
place ;  the  trochanter  is  nailed  to  the  shaft  and  the  muscle  flap  sutured 
as  shown  in  Fig.  389.  The  skin  is  sutured  with  silkworm  gut.  Drain- 
age is  not  emplayed  except  for  a  special  reason.     The  protective  dress- 


840     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


ing  is  applied  and  the  limb  placed  in  a  Buck's  extension  (p.  739)  ; 
it  is  not  immohilized  in  gypsum.  The  sutures  are  removed  on  the 
tenth  day. 

The  after  treatment  is  the  same  as  is  described  in  connection  with 
arthrectomv.     The  early  employment  of  massage,  passive  motion  and 


Fig.  389. —  Arthroplasty  of  the  ITip  .Jotxt. 

The  trocliaiiter  has  been  nailed  back  in  place  and  the  muscle  sutured, 
is  approximated  with  silkworm  gut  (from  Murphy  Clinics). 


The  skin 


the  prompt  application  of  ambulatory  apparatus  must  not  be  disre- 
garded. 

Arthrodesis  is  employed  for  the  relief  of  so-called  dangle  hips  due 
to  paralysis,  osteo-arthritis,  etc.  The  technic  of  Albee,^  other  than  the 
incision,  may  be  described  as  follows :  The  joint  is  exposed  through 
the  goblet  shaped  incision  of  Murphy-^  (Fig.  383).  The  capsule  is 
opened  and,  with  the  head  of  the  bone  in  situ,  one  third  of  its  upper 
hemisphere  is  removed  with  a  long  osteotome  or  chisel  —  five  eighths 
of  an  inch  in  v/idth  —  on  a  plane  nearly  parallel  with  the  long  axis 


OPERATIONS  ON  BONES  AND  JOINTS  841 

of  the  neck  of  the  femur.  With  the  same  instrument,  and  a  strong 
curette,  the  acetabulum  is  transformed  into  a  flat  surfaced  roof, 
against  which  the  flat  surface  of  the  caput  is  finally  brought  into  firm 
contact  by  abduction  of  the  thigh.  The  head  of  the  bone  is  then 
delivered  from  the  acetabulum,  as  shown  in  Murphy's  operation  (Fig. 
387),  and  the  cartilage  is  removed  from  the  former.  The  head  of  the 
femur  is  then  placed  back  into  the  prepared  pan;  the  trochanteric 
muscle  flap  is  fastened  in  place.  Of  course,  the  interposition  of  a  fat 
and  fascia  flap,  as  is  employed  in  connection  with  arthroplasty,  is 
omitted.  The  wound  is  not  drained  and  is  closed  in  the  same  way  as 
is  described  in  connection  with  arthroplasty.  The  protective  dressing 
is  applied  and,  as  ankylosis  is  aimed  at,  the  limh  is  immediately  imma- 
hilized  in  a  gypsum  spica,  in  strong  abduction  and  10°  flexion.  If 
convalescence  is  uneventful,  the  patient  is  permitted  to  walk  on 
crutches  in  five  weeks.  A  short  gypsum  spica  is  worn  for  seven  weeks 
more  (Albee^). 

The  Knee  Joint. —  Arfhrocentesis  is  practiced  more  frequently  in 
connection  with  the  knee  than  with  any  other  joint;  probably,  be  it 
said  to  our  shame,  because  of  its  easy  accessibility.  The  joint  is 
aspirated  for  the  removal  of  exudate  and  for  diagnostic  purposes. 
After  painting  the  skin  with  iodin,  the  aspirating  needle  (Fig.  364) 
is  made  to  enter  the  joint  at  its  internal  inferior  aspect  (Fig.  390), 
The  needle  is  gradually  advanced  until  its  point  is  located  beneath  the 
patella ;  as  the  contents  are  evacuated  the  needle  is  slowly  withdrawn 
until  the  joint  is  emptied.  The  aspirator  may  now  be  connected  with 
a  receptacle  containing  one  of  the  various  agents  used  for  injection 
into  the  joint.  As  already  stated,  the  latter  is  not  much  practiced  at 
this  writing,  though  it  still  has  its  exponents.  After  the  needle  is 
withdrawn,  the  tin}'-  puncture  wound  is  sealed  (with  collodion)  and 
the  joint  immobilized  under  firm  pressure. 

Arthrotomy  for  drainage  is  practiced  for  the  relief  of  infectious 
synovitis  (pyogenic,  pneumococcus,  gonococcus,  etc.).  For  the  pur- 
pose, two  incisions,  about  two  and  a  half  inches  in  length,  the  middles 
of  which  correspond  to  a  point  one  half  inch  to  either  side  of  the  rim 
of  the  patella  opposite  its  center  (Fig.  390),  are  made  through  the 
skin  and  carried  into  the  sjiiovia.  After  the  exudate  is  allowed  to 
escape  (do  not  squeeze  the  part),  a  fenestrated,  one-quarter  inch, 
rubber  drainage  tube  is  passed  through  the  joint  by  means  of  a 
slender  forcipressure  which  is  caused  to  enter  through  one  of  the 
incisions,  emerge  from  the  other,  and  gently  drag  the  tube  back  and 


842     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


out  through  the  port  of  entry.  The  joint  is  immobilized  on  a  posterior 
splint  and  the  protective  dressing  so  arranged  as  to  allow  the  drain- 
age tube  to  be  connected  with  a  tank  containing  Dakin's  solution 
(p.  245).  In  this  way  a  constant  supply  of  fresh  ''chlorine  generat- 
ing fluid"  is  instilled  into  the  joint.  This  method  has,  at  present,  an 
almost  w^orld  wide  field  of  application.  The  treatment  is  maintained 
until  the  discharge  from  the  joint  is  clean,  (see  Carrel  and  Dakin^^)^ 
A  not  uncommon,  and  very  effect- 
ive, practice  is  to  tampon  loosely 
the  joint  with  iodoform  gauze  (care 
being  taken  not  to  entirely  obstruct 
the  entrance  of  air,  p.  65)  and  to 
immobolize  the  joint  as  stated  im- 
mediately above.  The  gauze  tam-^ 
pon  is  changed  daily  and,  as  soon 
as  repair  is  established,  the  wounds 
are  apposed  bj^  suture. 

When  the  process  in  the  joint  has 
subsided,  passive  motion,  massage 
and  mechanicotherapy  are  begun. 
Despite  the  assiduous  employment 
of  these  measures,  ankjdosis  of  the 
joint  is  a  frequent  sequel. 

In  arihroiomy  for  the  removal  of 
a  corpus  mobile  (joint  mouse)  or  an 
injured  semilunar  cartilage  (p. 
760),  the  joint  is  opened  by  means 
of  one  of  the  vertical  incisions  just 
described  (Fig.  390).  The  dire 
results  following  infection  of  the 
knee  joint  justify  reiterating  at 
this  time  the  necessity  for  the 
rigid    employment    of    asepsis    in    connection    with    the    operation. 

When  the  corpus  mobile  is  located,  it  is  seized  with  forceps  and 
removed.  A  partially  detached  semilunar  cartilage  is  separated  with 
the  scissors  and  removed  (suturing  of  the  cartilage  is  no  longer  prac- 
ticed). While  the  fingers  should  not  be  introduced  into  the  joint,  it 
■  is,  at  times,  impossible  to  otherwise  locate  the  offending  agent.  When 
the  latter  is  not  located  through  one  incision  the  second  one  (Fig, 
390)  is  made. 


Fig, 


390. —  Phantom  op  Knee 
Joint  Showing: 


a,  aspirating  needle  introduced  into 
joint;  b,b,  two  arthrotomy  in- 
cisions; 0,  transverse  incision  for 
arthrectomy;   d,  curved  incision  for 

arthrodesis. 


OPERATIONS  ON  BONES  AND  JOINTS  843 

After  the  purpase  is  accomplished,  the  capsule  is  closed  with  catgut 
(no  drainage  is  emplo^'ed)  and  the  skin  sutured  with  silkworm  gut. 
The  knee  is  immobilized  for  ten  days,  when  the  sutures  are  removed 
and  passive  motion  and  mechanicotherapy  is  begun.  Even  when 
primary  union  is  attained,  a  certain  degree  of  stiffness,  w^hich  persists 
for  a  long  time  (months),  follows  the  operation.  The  pathology  of 
the  corpus  mobile  is  extensively  discussed  above  (p.  760). 

Arthrectomy  aims  at  removal  of  alx.  the  diseased  bont:  and  soft 
farts  of  the  joint  and  the  permanent  immobilization  of  the 
BONES  IN  GOOD  POSITION.  The  Operation  differs  from  arthrodesis  per  se 
(to  be  described  later)  in  that  the  latter  is  performed  for  flail  joint  or 
for  ankylosis  (following  a  healed  process)  in  a  faulty  position,  while 
arthrectomy  involves  the  removal  of  diseased  joint  tissue  and  bone. 

The  transverse  incision  (Fig.  390),  with  section  of  the  patella,  is 
the  one  used  at  this  time  by  most  surgeons.  The  semilunar  flap 
method  (attributed  to  Moreau^^)  and  the  lateral  hook  incision 
(attributed  to  Kocher^'*)  do  not  possess  any  advantages  over  the 
straight  transverse.  The  voluminous  arguments  as  to  prcsers^ation  of 
the  patella  may  be  answered  by  stating  that  this  is  determined  by  the 
conditions  found  upon  opening  the  joint,  and  that  its  removal  or 
repair  by  suture  is  readily  accomplished  through  the  transverse 
incision. 

The  incision  is  made  from  the  back  of  one  condyle  to  the  other. 
The  soft  parts  are  dissected  back,  exposing  the  entire  joint  area,  the 
patella  is  cut  across  with  the  bone  saw  (Fig.  332)  and  the  two  sections 
freed  on  both  sides  with  the  knife,  which  permits  the  fragments  to  be 
turned  upward  and  downward  (Fig.  331)  ;  or,  if  necessary,  these  may 
be  removed  at  once.  As  the  joint  is  now  fully  exposed  the  surgeon 
proceeds  to  excise  carefully  and  thoroughly  all  of  the  s^-novia,  especial 
attention  being  paid  to  the  projection  of  the  latter  under  the  vasti 
muscles.  The  crucial  ligaments  are  next  removed.  Ollier^^  advises 
that  the  lateral  ligaments  be  saved  if  possible.  The  semilunar  car- 
tilages are  examined  and  removed  if  necessary.  The  back  of  the  joint 
is  attacked  with  some  ditficulty ;  if  complete  arthrectomy  is  indicated, 
it  is  best  to  make  the  bone  sections  at  this  time,  a  step  that  makes  the 
posterior  aspect  of  the  joint  readily  accessible.  "When  this  is  not  done, 
all  the  diseased  tissues  in  this  situation  are  removed,  care  being  taken 
to  avoid  injury  to  the  popliteal  vessels.  The  operation  thus  far 
described  is  really  the  one  generally  designated  as  an  erasion,  and  in. 


844     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

our  terminology  is  called  a  partial  arthrectomy :    it  has  a  distinct  field 
of  usefulness. 

When  removal  of  the  bones  is  decided  upon,  the  femur  is  attacked 
first.  It  is  firmly  held  by  an  assistant  while  the  surgeon  marks  out 
the  site  of  the  proposed  section  with  a  scalpel ;  this  usually  corresponds 


Fig.  391. —  Transpatellar  Arthrectomy  of  Knee  Joint. 


to  the  junction  of  the  upper  and  middle  thirds  of  the  condyles.  The 
section  is  made  with  the  bone  saw,  care  being  taken  that  the  plane  of 
the  sawed  surface  is  at  right  angles  to  the  axis  of  the  shaft.  A  groove 
is  cut  on  the  tibia  about  half  an  inch  below  the  articular  surface. 
The  bone  saw  cuts  from  behind  forward  (Fig.  392).  When  the  ends 
of  the  bones  are  removed,  there  would  not  seem  to  be  any  object  in 


OPERATIONS  ON  BONES  AND  JOINTS 


845 


preserving  the  patella.  When  a  partial  arthrectomy  is  done,  the 
patella  may  be  sutured  as  described  in  connection  with  fracture 
(p.  791).  In  either  event  the  joint  is  drained  at  its  posterior  lateral 
aspects,  with  a  hank  of  silkworm  gut  passed  through  the  joint. 

As  to  fixation  of  the  refreshed  ends  of  the  femur  and  tibia,  the 
older  surgeons  rely  upon  the  application  of  a  suitable  dressing.     The 


Fig.  392. —  Complete  Arthrectojiy  of  Knee  Joint. 

Articular  surface  of  tibia  about  to  be  sectioned  with  Gigli-Hartel  saw  from 
behind.     The  femoral  surface  has  already  been  removed. 

problem  does  not  differ  in  any  essential  regard  from  that  presented 
in  connection  with  the  operative  treatment  of  fractures,  and  wire, 
nails,  plates,  ivor}'-  pegs,  etc.,  all  have  their  supporters.  It  would 
seem,  however,  that  the  conditions  are  ideal  for  the  use  of  bone  peg 
transplants;  these  are  best  obtained  from  the  fibula  and  are  intro- 
duced in  precisely  the  same  manner  as  is  described  in  connection  with 
the  medullar}'  bone  transplant  (p.  803),  except  that  two  bone  dowels 


846     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


are  used.     Figure  393  shows  the  manner  in  which  this  was  done  by 
the  writer.     The  ultimate  result  was  very  satisfactory. 

It  is  often  necessary  to  trim  off  redundant  portions  of  the  skin  flaps. 
The  wound  is  closed  with  silkworm  gut,  the  protective  dressing  is 
applied  and,  as  union  of  the  bones  is  aimed  at,  the  limb  is  immobilized 
in  gypsum.  The  latter  is  arranged  so  that  the  wound  is  accessible. 
As  a  rule,  the  drain  is  left  in  situ  for  ten  days,  when  it,  together  with 
the  sutures,  is  removed.  Immobilization  of  the  joint  area  is  main- 
tained for  three  months;  during  this  time,  however  (i.  e.,  after  the 
wound  is  healed),  the  apparatus  is  removed  daily,  the  leg  and  thigh 
massaged  and  the  ankle  joint  and  hip  are 
permitted  to  functionate. 

Arthroplasty  in  connection  with  the 
knee  joint  does  not  hold  out  the  same 
promise  as  obtains  in  connection  with  the 
hip.  It  has,  however,  given  excellent  re- 
sults in  cases  of  ankylosis  following  infec- 
tion (pyogenic,  pneumococcic,  gonococcic, 
etc.).  As  in  all  plastic  operations,  it  does 
not  accomplish  the  intent  in  the  presence 
of  an  inflammatory  process. 

For  the  purpose,  Murphy^^  makes  two 
anterolateral  incisions  similar  to  those  em- 
ployed for  arthrotomy  for  drainage  (Fig. 
390).  Both  sides  of  the  joint  are  pre- 
pared by  denuding  the  condyles  and  the 
tibia,  as  shown  in  Fig.  394.  These  bones 
are  separated  by  means  of  an  especially 
constructed  gouge,  the  curve  of  which 
corresponds  in  a  general  way  to  the  out- 
line of  the  articular  surfaces  of  the  bones,  and  the  patella  is  freed 
with  an  ''artist's  chisel."  Fig.  394  shows  this  as  stated,  and  also 
shows  the  fascia  and  fat  flap  dissected  up  from  the  tibiofemoral 
aspect  of  the  joint  area,  ready  for  interposition  between  the  tibia 
and  femur  when  these  are  refreshed.  Sufficient  of  the  articular 
surfaces  of  the  bones  is  removed  (by  means  of  the  special  gouge) 
to  permit  of  free  passive  flexion  of  the  newly  made  joint;  a  flap  is 
fashioned  from  the  soft  parts  overlying  the  lower  end  of  the  femur 
(Fig.  395)  and  is  placed  between  the  patella  and  the  anterior  surface 
of  the  condyles  (Fig.  396).    The  flap  from  the  outer  side  of  the  joint 


Fig.  393. —  Manner  op  Fixing 
THE  Bones  with  Bone 
Dowels  After  Complete 
Arthrectomy  of  the  Knee 
Joint. 


OPERATIONS  ON  BONES  AND  JOINTS 


847 


is  ''tucked"  into  the  new  joint  and  a  similar  one  is  fashioned  on  the 
inner  side  aiid  is  inserted  from  that  side.  These  flaps  overlap  and 
are  fastened  with  chromic  gut  as  shown  in  Fig.  397.  Two  subpatellar 
flaps  (the  one  mentioned  and  another  from  the  opposite  side  of  the 
anterofemoral  region)  are  slipped  under  the  patella,  one  on  top  of 
the  other.  Fig.  397  shows  the  internal  subpatellar  flap  sutured  in 
place  at  the  outer  side  of  the  joint  and  the  external  one  ready  to  place 
over  it.    The  tibiofemoral  flap  from  the  internal  side  is  slid  over  the 


Fig.  394. —  Arthroplasty  of  the  Knee  Joint. 

The  femur  and  tibia  are  being  separated  by  means  of  the  gouge  and  chisel ;  the 
patella  is  being  loosened  by  means  of  the  "artist's  chisel."  The  flap  to  be 
interposed  between  the  femur  and  the  tibia  is  held  in  readiness  (from  Murphy 
Clinics). 


one  already  placed  in  the  joint  from  the  external  side  and  is  fastened 
over  the  latter.  This  means  that  two  fascia  and  fat  flaps,  one  above 
the  other,  rest  between  the  articular  surfaces  of  the  bones,  and  two 
lie  between  the  under  surface  of  the  patella  and  the  anterior  surfaces 
of  the  condyles,  each  flap  being  sutured  in  place  through  the  wound 
opposite  the  one  where  it  is  fashioned. 

Draiyiage  of  the  joint  is  not  cmploijed.  The  superficial  Avounds 
may  be  drained  with  a  few  strands  of  silkworm  gut  or  with  a  rubber 
tissue  drain  for  forty-eight  hours,  to  take  care  of  the  oozing.  A  Buck's 


848     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

extension  (p.  656)  is  applied  (below  the  knee)  and  the  limb  is 
placed  on  a  curved  wire  splint,  which  also  holds  the  protective  dress- 
ing in  place.    The  sl^in  sutures  are  removed  in  two  weeks. 

The  after  treatment,  which  consists  in  massage,  passive  motion  and 
mechanotherap}',  is  begun  at  the  end  of  the  third  week. 

Arthrodesis  follows  complete  or  partial  arthrectomy  and  is  regarded 
as  a  fortunate  outcome  in  this  class  of  cases.  As  a  distinct  operative 
measure  it  is  employed  for  the  relief  of  flail  joint,  and  in  tulerculous 
arthritis  without  extensive  bone  involvement. 


Fig.  395.- —  Arthroplasty  of  the  Knee  Joixt. 

Articular  surface  of  femur  and  tibia  ready  for  insertion  of  interposing  flap. 
Subpatellar  flap  prepared   (from  Murphy  Clinics). 

Albee^  exposes  the  joint  hy  means  of  a  curved  incision  with  its  con- 
cavity upward  (Fig.  390).  It  begins  at  one  femoral  condyle  and 
crosses  and  divides  the  patellar  ligament  one  inch  above  its  insertion. 
The  deeper  structures  overl^-ing  the  joint  are  turned  upward  (Fig. 
398),  the  crucial  (if  present)  and  the  lateral  ligaments  are  divided 
and  the  upper  end  of  the  tibia  drawn  forward.  The  patella  is  denuded 
of  its  articular  surface  by  means  of  a  bone  saw ;  it  is  then  enucleated, 
and  laid  aside  wrapped  in  a  towel  wet  with  saline  solution.    With  the 


OPERATIONS  ON  BONES  AND  JOINTS 


849 


same  saw  the  upper  articular  surface  of  the  tibia  is  removed,  cutting 
from  iu  front  backward  so  as  to  form  a  concave  surface ;  following  this, 
the  articular  surfaces  of  the  condyles  of  the  femur  are  removed,  form- 
ing a  flat,  ovoid  surface,  slightly  convex  from  in  front  backward,  and 
fitting  the  concavity  of  the  upper  cut  end  of  the  tibia  (Fig.  399  a). 
These  surfaces  are  apposed.  "With  the  twin  motor  saw  two  gutters 
are  formed  across  this  line  of  apposed  femur  and  tibia.  One  gutter, 
about  one  half  inch  wide  and  two  inches  long  —  depending  upon 
the  side  of  the  patella,  is  made  from  the  external  condyle  into  the 


g'-       Ex  fern  a!    surf^ace    \ 

V 

n 

■■F"        ^.^ ^'■ili^H 

^ 

^^1 

L 

m^ 

^ 

B 

r«l^g*^^a^ajMSiS^''K'^!WIIIWff^CTf^  ^^ 

ifcfeiJ^- 

Fig.  396. —  Aetheoplasty  of  the  Kxee  Joixt. 

The  external  tibiofemoral  flap  inserted  and  outer  edge  of  internal  patellar 
flap  sutured  into  place.    External  patellar  flap  prepared  (from  Murphy  CUmcs). 

outer  and  anterior  portion  of  the  head  of  the  tibia,  and  another 
^tter  of  the  same  dimensions  is  formed  across  from  the  internal 
condyle  to  the  anterior  surface  of  the  tibia.  The  segments  of  bone 
thus  formed  are  liberated  with  the  small  motor  saw  and  are  removed 
with  a  thin  narrow  chisel. 

The  twin  motor  saw,  adjusted  to  the  same  width  as  when  forming 
the  gutters,  is  used  in  cutting  from  the  patella  two  strips  (Fig.  399  b) 
which  are  used  to  bridge  the  femur  and  tibia  and  fit  tightly  the  previ- 
ously prepared  gutters  (Fig.  399  c) .    Holes  are  drilled  on  either  side 


850    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


of  the  gutters,  with  the  small  motor  drill,  in  both  the  head  of  the  tibia 
and  the  femoral  condyles  and  strong  kangaroo  tendon  sutures  are 
passed  and  tied  over  both  ends  of  the  two  patellar  grafts,  in  the  man- 
ner shown  in  connection  with  repair  of  fractures  (Fig.  357).  If  the 
patella  is  diseased  a  tibial  graft  (p.  804)  may  be  used.  A  slender 
hank  of  silkworm  gut  is  introduced  into  the  posterior  aspect  of  the 
joint  for  drainage  and  the  flap  is  sutured  with  the  same  material.  As 
ankylosis  is  aimed  at,  the  limb  is  inimediately  immohilized  in  gypsum. 
The  after  treatment  is  the  same  as  that  employed  following  arthrec- 


FiG.  397. —  Arthroplasty  of  the  Knee  Joint. 

Flap  work  completed.     Note  the  tibial  flaps  placed  one  on  top  of  the  other 
and  a  similar  arrangement  of  the  subpatellar  flaps   (from  Murphy  Clinics). 

tomy  (p.  843).  As  in  all  transplant  work,  the  repair  is  likely  to  be 
rapid. 

Habitual  dislocation  (outivard)  of  the  patella  has  been  subjected  to 
many  operative  measures  of  relief.  Most  of  these  attempt  to  restrict 
the  lateral  motility  of  the  bone  by  attacking  the  soft  parts  (Krogius^®, 
Murphy-^,  Tenney",  Whitlock^^,  Goldthwait^",  and  others).  Graser*'' 
does  a  supracondjdoid  osteotomy  and  twists  the  outer  condyle  so  that 
it  is  too  high  for  the  patella  to  slip  over.  Of  the  methods,  that  of 
Albee^  makes  the  greatest  appeal.     It  is  substantially  as  follows : 

A  semilunar  incision  is  made  to  the  outer  side  of  the  patella  suffi- 


OPEHATIONS  ON  BONES  AND  JOINTS 


851 


ciently  long  to  reach  below  the  tibial  tubercle  and  above  the  external 
condyle.  With  the  least  possible  disturbance  to  the  underlying 
joint  structures,  the  external  condyle  is  incised  on  its  external 
surface  -  with  a  broad,  thin  osteotome,  making  a  bone  incision  of 
from  one  and  a  half  to  two  inches  in  length  and  about  one  half  inch 
below  its  anterior  articular  surface  and  nearly  in  line  with  the  long 

axis  of  the  femur.  This 
bone  incision  allows  the 
anterior  surface  of  the 
external  condjie  to  be 
raised  to  a  plane  above 
the  internal  condyle  by 
producing  a  green  stick 
fracture  near  the  inter- 
condylar groove,  the  ob- 
ject being  to  place  a 
permanent  and  rigid  ob- 
stacle in  the  way  of 
the  outward  displace- 
ment of  the  patella. 
When  the  anterior  seg- 
ment of  the  external 
condyle  has  been  pried 
forward  sufficiently  to 
demonstrate  its  mechani- 
cal efficiency,  the  width 
of  the  bone  gap  thus 
formed  is  measured  and 
a  section  of  bone  suf- 
ficiently large  to  fill  this 
cuneiform  gap  is  removed 
from  the  crest  of  the 
tibia  through  the  lower 
portion  of  the  same  skin  wound  by  extending  the  latter  below  the 
tubercle.  This  bone  graft  w^edge  can  be  very  easily  and  quickly  fash- 
ioned with  the  motor  saw.  Before  the  bone  gi*aft  is  removed,  it  is 
obliquely  drilled  in  one  or  two  places  by  means  of  the  motor  drill,  so 
that  it  may  be  pegged  to  the  under  portion  of  the  external  condyle 
when  put  in  place.  The  dowel  pins  are  fashioned  by  the  motor  lathe, 
from  an  additional  portion  of  bone  removed  from  the  crest  of  the  tibia 


Fig.  398. —  Knee  Joint  Exposed  for  Arthrodesis. 

Cartilaginous  layer  from  posterior  surface  of 
patella  being  sawed  off  preliminary  to  its  enuclea- 
tion and  division  into  grafts  (from  Albee's  "Bone 
Graft  Surgery"). 


852    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

at  the  time  the  graft  is  obtained.  The  consistence  of  the  structure  of 
the  condyle  usually  permits  the  bone  graft  pegs  to  be  driven  into 
place;  however,  suitable  canals  may  be  made  with  the  drill.  Fig. 
400  shows  the  graft  wedged  under  the  elevated  external  condjde. 
The  deep  incision  is  closed  over  the  site  of  the  graft.  The  skin  is 
closed  with  silkworm  gut,  without  drainage,  and  the  limb  is  immobil- 
ized in  a  removable  gj^psum  splint  for  three  weeks,  after  which  mas- 


^  B  c 

Fig.  399. —  A,  Shows  the  Line  of  Eemoval  op  the  Articulating  Surfaces  op 
THE  Femur  and  Tibia  by  Means  of  the  Nakrow  Bone  Saw,  in  Producing 
Arthrodesis  of  the  Joint.  B,  Splitting  the  Patella  Into  Segments  by 
THE  Twin  Motor  Saw,  to  Produce  Two  Bone  Grafts  to  Be  Placed  in  the 
Gutters  (C)  Sawed  from  the  Two  Condyles  of  the  Femur  and  the  Head  of 
THE  Tibia  (from  Albce's  "Bone  Graft  Surgery"). 


sage  and  passive  motion  are  begun.  The  skin  sutures  are  removed 
on  the  tenth  day.  Albee^  suggests  that  a  very  lax  capsule  be  plicated 
with  three  kangaroo  tendon  sutures,  but  states  that  this  should  rarely 
be  necessary. 

The  Ankle  Joint. — Ankylosis  of  the  talocrural  joint  does  not  respond 
favorably  to  operative  efforts  directed  toward  the  establishment  of 


OPERAnONS  ON  BONES  AND  JOINTS 


853 


motion.  This  in  due  iu  part  to  the  fact  that  its  approach  is  made 
difficult  by  the  numerous  tendons  which  cross  it.  When  once  the 
anterior  annular  ligament  is  cut,  the  function  of  the  entire  foot  is 
likely  to  be  interfered  with.  It  is  a  fortunate  circumstance  that  anky- 
losis of  the  joint  at  right  angles  to  the  leg  does  not  interfere  very 
greatly  with  locomotion.  This  should  be  borne  in  mind  in  the  treat- 
ment of  lesions  in  tliis  situation,  a  warning,  especially  worthy  of 
consideration  in  the  care  of  the  foot  during  the  early  stages  of  paraly- 
sis of  the  anterior  tibial  group  of  muscles  and  in  the  treatment  of 
malleolar  fractures. 


Fig.   400. — -Albee's   Operation   for   Outward    (Habitual)    Luxation   of   the 

Patella. 

Shows  shape  of  graft  in  position,  lifting  the  anterior  portion  of  the  external 
condyle  to  jireveut  recurrence  of  the  luxation  (from  Albee's  "Bone  Graft 
Surgery"). 


Arthrocentesis  of  the  ankle  joint  is  employed  for  diagnostic  pur- 
poses and  for  the  removal  of  bloody  exudate  in  connection  with  mal- 
leolar fractures  and  those  of  the  talus;  it  should  he  performed  more 
often  than  it  is.  After  painting  the  skin  with  iodin,  the  needle  of  the 
aspirator  (Fig.  364)  is  entered  one  quarter  of  an  inch  in  front  of  the 
internal  malleolus  and  one  half  inch  above  its  tip.  After  the  contents 
of  the  joint  are  evacuated  the  needle  is  withdrawn  and  the  puncture 
wound  sealed  with  collodion. 

Arthrofomy  for  drainage  is  accomplished  by  means  of  two  lateral 
incisions  (Fig.  401)  described  in  connection  with  arthrectomy  (p.  854) 


854    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

(the  surface  of  the  joint  being,  of  course,  prepared  in  the  usual 
manner).  The  operation  is  employed  for  the  evacuation  of  exudate. 
After  the  joint  is  opened,  this  is  encouraged  b}^  means  of  gentle 
manipulations,  following  which  a  slender  forceps  is  passed  through 
the  joint  cavity  (from  either  side)  ;  the  distal  end  of  the  instru- 
ment grasps  a  one  quarter  inch  fenestrated  rubber  drainage  tube, 
which  is  caused  to  tranverse  the  joint  as  the  forceps  is  withdrawn 
and  made  to  protrude  from  the  proximal  wound.  The  joint  is  not 
lavaged,  though  many  surgeons  do  this,  using  various  antiseptic 
solutions  for  the  purpose.  Of  these,  the  Carrel-Dakin  solution  (p. 
246)   is  largely  used  in  the  manner  described  in  connection  with  the 


Fig.  401. —  The  External  and  Internal  Arthrotomy  or  Arthrectomy 

Incisions. 


knee  joint.  A  silkworm  gut  suture  is  inserted  into  the  soft  parts 
of  each  w^ound,  above  the  point  of  egress  of  the  tube,  and  the  foot 
and  leg  are  encased  in  gypsum  as  shown  in  Fig.  402.  The  tube 
is  removed  when  the  discharge  of  exudate  ceases  and  passive  motion 
is  begun  as  soon  as  the  irritation  in  the  joint  subsides. 

Arthrectomy  is  accomplished  through  two  lateral  incisions  (Fig. 
401).  The  inner  one  begins  over  the  tibia  three  to  four  cm.  above 
the  level  of  the  joint,  internal  to  the  extensor  tendons,  and  opens  the 
joint  close  to  the  anterior  edge  of  the  malleolus.  It  crosses  the  body 
and  neck  of  the  talus  and  ends  at  the  medial  edge  of  the  foot  over  the 
tuberosit}^  of  the  navicularis.  The  outer  incision  paralk^ls  the  inner 
one  and  is  made  along  the  posterior  edge  of  the  fibula;  it  opens  the 


OPERATIONS  ON  BONES  AND  JOINTS 


50D 


joint  at  the  malleolus  and  ends  on  a  level  with  the  talonavicular  joint 
(Fig.  401).  The  anterior  bridge  of  soft  parts,  which  contains  the 
extensor  tendons,  the  blood  vessels  and  the  nerves,  is  lifted  with  the 
elevator,  the  anterior  aspect  of  the  capsule  being  raised  at  the  same 
time  from  the  talus  and  the  edge  of  the  tibia ;  the  anterior  portion  of 
the  synovia  (when  necessary)  is  excised.  By  flexing  the  foot  the 
anterior  soft  parts  may  be  sufficiently  raised  to  make  the  various  por- 
tions of  the  joint  fairly  accessible  to  instrumentation.  The  taliLs  may 
be  removed  through  the  inner  incision  with  comparative  case,  which 
makes  the  lower  ends  of  the  bones  of  the  leg  accessible  through  this 
and  through  the  external  incision.     Various  other  incisions  are  em- 


FiG.  402. — ■  Bracketed  Suspensiox  Gypsum  Splint  for  Arthrectomt  of  Ankle 

Joint. 
The  drainage  tube  is  also  shown. 


ployed  for  the  purpose  (see  Brj-ant*^) .  None  of  these,  however,  would 
seem  to  possess  any  advantage  over  those  described,  especially  in  cases 
in  which  the  removal  of  the  articular  ends  of  the  bones  of  the  leg  and 
the  talus  becomes  necessary. 

The  joint  is  drained  with  a  rubber  drainage  tube  and  the  wounds 
are  closed  with  silkworm  gnt.  After  the  protective  dressing  is 
applied,  the  leg  and  foot  are  encased  in  gj^psum  as  shown  in  Fig. 
402.  The  use  of  gj-psum  is  ad\dsed  in  these  eases  on  the  grounds 
stated  above.  The  drainage  tube  is  withdrawn  as  soon  as  discharge 
of  the  exudate  ceases.     The  sutures  are  removed  on  the  tenth  day.     As 


856     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

it  is  usually  desirable  that  ankylosis  follow  the  operation,  the  ankle  is 
held  still  until  this  is  achieved.  That  is  to  sa}',  arthrectoniy  is,  in 
most  instances,  the  step  which  removes  the  pathological  process  and, 
at  the  same  time,  aims  at  arthrodesis.  It  is  necessary  to  add  that 
partial  arthrectomij,  in  which  only  a  restricted  portion  of  the  joint 
surfaces  is  removed,  is,  at  times,  followed  by  a  limited  degree  of 
motion  in  the  joint,  though,  unfortunately',  this  is  very  likely  to  be 
painful  on  locomotion.  However,  Albee^  has  devised  an  operation 
(described  below)  which  is,  in  a  way,  a  fixation  operation,  yet  is  fol- 
lowed by  a  certain  amount  of  satisfactory  motion  in  the  joint.  At  the 
end  of  ten  to  fourteen  days,  the  gypsum  splint  is  modified  so  that  it 


FiG.  403. —  Kocher's   Method  for  Approach   to  the 
Ankle  Joint, 

The  method  is  employed  in  connection  with  excision 
of  the  talus  and  for  the  Wredc-Albee  arthrodesis  oper- 
ation. 


becomes  feasible  to  gain  access  to  the  limb  each  day  for  the  purpose 
of  massage  (avoiding  the  wound  area)  and  in  order  to  move  the  knee 
and  the  tarsal  joints,  measures  which  contribute  much  to  the  speedy 
return  of  function. 

Arthroplasty  at  the  ankle,  as  such,  is  not  a  very  successful  opera- 
tion; however,  that  ingenious  pioneer,  Albee^  (who  credits  Wrede*^ 
with  the  original  technic),  employs  a  method  which  is  a  partial 
arthrectoniy,  a  partial  arthroelesis  and  an  arthroplasty  in  one.  It  is 
indicated  in  cases  of  flail  joint  due  to  paralysis,  and  "does  not  com- 
pletely ankylose  the  joint."    The  ankle  joint  having  been  exposed  'by 


OPERATIONS  ON  BONES  AND  JOINTS 


857 


the  Kocher  incision  (Fig\  403),  the  astragalus  is  removed  without 
being  fractured.  The  cartilaginous  surfaces  of  the  astragalus,  as  well 
as  those  of  the  bones  articulating  with  it,  are  removed.  Albee^  uses 
the  electric  motor  saw  and  burrs  to  accomplish  this.  The  astragalus, 
denuded  of  its  periosteum,  is  then  replaced  in  its  normal  site.  The 
wound  is  closed  (without  drainage)  and  a  gypsum  dressing  applied 


Fig.    404. —  EONTGENOGRAM    SHOWING   THE   IMaNNER   OF   UsiNG   TIBIAL   GRAFTS   FOR 

THE  Purpose  of  Fixing  the  Ankle  Joint. 
The  hypertrophy  and  increase  in  density  of  the  graft  are  very  striking,  especi- 
ally at  JB  and  I).     The  fibula,  into  which  they  are  inserted,  is  even  hypertrophied 
frcm  increased  stress  (from  Albee's  "Bone  Graft  Surgery"). 


for   twelve  weeks.     Fibrous   union    (with   some  motion),   not  bony 
ankylosis,  follows. 

Arthrodesis,  i.  e.,  fixation  of  the  ankle  joint,  is  accomplished  by  many 
surgeons  by  denuding  the  articular  surfaces  of  the  astragalus,  the 
fibula  and  the  tibia,  and  subsequently  nailing  these  bones  together 
(Murph}'-^).     Albee^  has  succeeded  in  achieving  the  desired  end  in  a 


858     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


manner  wliich  seems  to  overcome  the  objectionable  features  of  the 
older  methods.     He  uses  three  grafts  :    One  from  the  internal 

MALLEOLUS  TO  THE  OS  CALCIS  ; 
A  SECOND  FROM  THE  INTER- 
NAL MALLEOLUS  TO  THE  IN- 
TERNAL CUNEIFORM  BONE ; 
AND  A  THIRD  FROM  THE  EX- 
TERNAL MALLEOLUS  TO  THE 
CUBOID  BONE. 

A  U-shaped  skin  flap  is 
turned  up,  exposing  the  in- 
ternal malleolus.  A  bed  for 
the  fixation  of  the  joined 
ends  of  the  grafts  coming 
from  the  internal  cuneiform 
bone  and  the  os  calcis  is  pre- 
pared. As  these  grafts  are 
to  be  joined  at  an  obtuse 
angle,  in  the  manner  of  an 
inverted  V,  the  bed  is  pre- 


FiG.  405. —  Eesection  of  the  Foot. 
The  various  steps  of  the  Wladimiroff -Mikulicz  operation. 

pared  by  turning  one   osteoperiosteal   flap   down  and  two  upward 
by  means  of  a  sharp  osteotome.     Short  skin  incisions  are  likewise 


OPERATIONS  OX  BONES  AND  JOINTS  859 

made  over  the  inner  surface  of  the  posterior  portion  of  the  os  calcis 
and  internal  cuneiform  bone,  and  beds  are  prepared  for  the  ends 
of  the  grafts  by  turning  up  osteoperiosteal  flaps.  Subcutaneous  tun- 
nels are  made  with  a  hj-sterectomy  clamp,  joining  these  incisions  with 
the  one  over  the  internal  malleolus.  The  length  of  the  grafts  is  deter- 
mined with  calipers.  The  grafts  are  then  obtained  from  the  tibia  in 
the  manner  described  above  (p.  802).  The  ends  of  the  two  grafts 
that  are  to  be  joined  at  the  internal  malleolus  are  mortised ;  these  are 
then  pushed  through  the  subcutaneous  tunnels  already  prepared  for 
them,  and  the  mortised  ends  are  joined  and  covered  by  the  osteo- 
periosteal flaps  which  are  drawn  over  them  and  apposed  b}'  kangaroo 
tendon.  The  other  ends  of  these  grafts,  as  well  as  the  graft  implanted 
on  the  outer  side  of  the  foot,  are  secured  in  place  in  a  similar  manner. 
Fig.  401  shows  the  manner  in  which  the  grafts  have  been  introduced. 
The  skin  wounds  are  closed  with  silkworm  gut  sutures  and  the  foot 
and  leg  encased  in  gypsum,  with  the  former  at  right  angles  to  the 
latter. 

Resection  of  the  foot  is  employed  in  connection  with  lesions  re- 
stricted to  the  calcaneus,  the  talus  and  the  talocrural  joint.  The 
operation  is  classic  in  the  literature  under  the  name  of  the  Wladimi- 
roff-MiJi-uUcz  operation.  A  transverse  incision  is  made  across  the  sole 
of  the  foot,  a  second  across  the  posterior  aspect  of  the  ankle,  and  these 
are  connected  by  two  lateral  incisions  (Fig.  405).  The  talocrural 
joint  is  opened  from  behind  and  the  two  malleoli  are  sawed  off;  the 
tarsus  is  severed  in  the  region  of  the  cuboid,  thus  creating  the  con- 
dition of  affairs  shown  in  Fig.  405.  The  same  bone  surfaces  are 
apposed  by  suturing  the  soft  parts  as  presented  in  Fig.  405.  It  would 
seem  as  though  a  bone  graft,  such  as  is  employed  for  the  purpose  of 
fixing  fractures  of  long  bones  (see  medullary  bone  transplant,  p.  802), 
could  be  easily  introduced  into  the  tarsus  on  one  side  and  the  tibia  on 
the  other ;  a  step  which  would  probably  firmly  fix  the  bones  and  con- 
tribute to  the  stability  of  the  union.  The  after  treatment  is  similar  to 
that  employed  after  arthrodesis. 

BIBLIOGRAPHY 

1.  Albee.     Bone  Graft  Surs:.,  Saunders.  Phila.  and  London,  1915. 

2.  DoTEN.     Sura-.  Therap.  Oji.  Tech..  Wood  &  Co.,  N.  Y.,  1918. 

3.  Laxe.     The  Op.  Treat,  of  Fraet.,  Med.  Pub.  Co.,  London,  1914. 

4.  KoEXiG.     Quoted  by  Bryant,  Op.  Surg.,  Appleton,  N.  Y.  and  London, 

1905. 


860     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

5.  Cheyxe.     Same  as  Xo.  4. 

6.  rREEMAN.     Anns.  Surg.,  xl. 

7.  Davisox.     Surg.  Gyn.  Obst.,  1914,  xviii. 

8.  Davisox  and  Smith.     Autoplastic  Bone  Surg.,  Phila.,  1916. 

9.  Davisox.     Jr.  A.  M.  A.,  1914,  Ixii. 

10.  Murphy.     Surg.  G^ti.  Obst.,  1913,  xiv. 

11.  Hexdersox  and  New.     Surg.  Gyu.  Obst.,  xxvii,  No.  5. 

12.  V.  Laxgexbeck.     Arch.  f.  clin.  Chir.,  xvi,  1874. 

13.  Ollier.     Paris,  18S8,  Ma&son  ii. 

14.  SOL'CHOX.     Trans.  Amer.  Surg.  Assoc,  1897. 

15.  McBurxey.     Anns.  Surg.,  Phila.,  April,  1894. 

16.  RiCARD.     Gaz.  des  Hop.,  Paris,  Ixv,  1892. 

17.  Gerster.    N.  Y.  Med.  Jr.,  1884. 

18.  BuRRELL.     Trans.  Amer.  Surg.  Assoc,  1897. 

19.  LoxGMORE.     Resection  of  Shoulder  Joint  in  Military  Surgery, 

20.  Jacobsox  and  Steward.     Op.  of  Surg.,  Blakiston,  Phila.,  1902. 

21.  V.  Laxgexbeck.     Arch.  f.  Chir.,  xxi,  1875. 

22.  Heath.     Op.  Surg.,  London,  1892. 

23.  AxxADALE.     Quoted  by  Jacobson,  Xo.  20. 

24.  Billroth.     Clin.  Chir.,  1877. 

25.  MacCormac.     Surg.  Operations,  Part  ii,  London. 

26.  Stimsox.     Trans.  Amer.  Surg.  Assoc,  ix. 

27.  Cluttox.     Brit.  Med.  Jr.,  De^c  16,  1893. 

28.  Murphy.     Murphy's  Clinics,  1913,  1914. 

29.  Ollier.     Cong.  Franc,  de  chir.,  1894. 

30.  Barker.     Brit.  Med.  Jr.,  1888,  1. 

31.  HtJTER.     See  Jacobson,  Xo.  20. 

32.  Carrel  and  Dakix.     Jr.  A.  M.  A.,  1916. 

33.  MoREAU.     See  Jacobson,  Xo.  20. 

34.  Kocher.     Quoted  by  Zuckerkandl,  ]\Iunich,  1905. 

35.  Ollier.     Rev.  de  Cliir.,  1882. 

36.  Krogius.     Zentrbl.  f.  Chir.,  190o. 

37.  Texxey.     Amer.  Surg.,  1908,  xlviii. 

38.  TVhitlock.     Brit.  Surg.  Jr.,  July,  1914. 

39.  Goldthwait.     Amer.  Jr.  of  Orthop.  Surg.,  i,  Xo.  3. 

40.  Graser.     Zentrbl.  f.  Chir.,  July  9,  1904. 

41.  Bryaxt.     Op.  Surg,  i,  Appleton,  X.  Y.  and  London,  19G5. 

42.  Wrede.     See  Albee,  Xo.  1. 


CHAPTER  VII 

AMrUTATIONS 

General  Considerations. — The  trend  of  the  day  is  to  deviate  from  the 
prescribed  method  of  amputating  a  limb  at  a  certain  sector  and  in 
each  case  to  apply  the  general  laws  governing  amputations,  fashioning 
flap:5  to  meet  the  special  indications.  It  is,  of  course,  necessary  for  the 
student  to  be  familiar  with  certain  classic  methods  of  procedure,  and, 
indeed,  these  methods  exemplify  the  principles  spoken  of  and  are, 
therefore,  helpful  in  a  general  way ;  however,  in  practice  these  too  will 
often  be  found  susceptible  of  advantageous  modification. 

The  ablation  of  a  part  is,  at  all  times,  performed  with  a  feeling  that, 
had  the  surgeon  exercised  greater  skill  in  the  care  of  the  lesion,  the 
part  might  have  been  saved.  This  feeling  is,  of  course,  not  often  avcU 
founded ;  on  the  other  hand,  it  is  also  true  that  amputations  are  not  as 
often  deemed  necessarj^  at  this  time  as  was  formerly'  the  case.  It  is 
also  gratifying  to  be  able  to  record  that  the  newer  methods  of  fash- 
ioning the  so-called  ''motor  stump"  have  somewhat  lessened  the  mis- 
fortunes attendant  upon  the  loss  of  an  extremit}^  (especiallj^  the 
upper)  and  that  these  have  been  still  more  compensated  for  by  the 
extremel}^  ingenious  artificial  limbs  now  available. 

A  STUMP,  TO  BE  SERVICEABLE,  SHOULD  BE  SOUND,  UNIRRITABLE,  AND 
HAVE    GOOD    CIRCULATION    AND    ABUNDANT    LEVERAGE     (J.    D.    Bryant'). 

The  flaps  at  the  extremity  of  the  stump,  after  healing  is  completed, 
should  be  freclij  movaMe,  except  at  the  seat  of  the  cicatrix — over  the 
underh'ing  tissues.  Integument  normally  subjected  to  pressure  (as 
that  of  the  palm  of  the  hand  or  the  sole  of  the  foot)  makes  the  hest 
covering  for  the  functionating  portion  of  the  stump.  The  proper  length 
of  flaps  is  an  important  consideration.    The  combined  length  of  the 

FLAPS  SHOULD  BE  EQUAL  TO  ONE  HALF  THE  CIRCUMFERENCE  OF  THE 
LIMB    AT    THE    POINT    WHERE    THE    BONE    IS    SECTIONED.       For    example, 

assuming  that  the  limb  is  20  cm.  in  circumference  at  the  point  where 
the  bone  is  to  be  sectioned,  the  combined  length  of  the  flaps  should  be 
10  cm. ;  i.  e.,  if  two  symmetrical  flaps  are  used,  each  one  is  5  cm.  in 

861 


862     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


length  (see  circular  and  bilateral  methods)  ;  or,  if  conditions  war- 
rant it,  one  may  be  6  cm.  and  the  other  4  cm.  in  length  (see  the 
Teale  amputation,  p.  895) ;  it 
is  even  permissible  to  make 
one  flap  8  cm.  and  the  other 
2  cm.  in  length.  The  latter  is 
exemplified  (in  the  same  pro- 
portions) in  Lisfranc  \s  ampu- 
tation (p.  888). 

It  is  desirable  that  the 
cicatrix  he  so  placed  as  not  to 
he  suhjected  to  undue  pres- 
sure or  friction  (see  Teale 's 
method,  p.  895)  ;  however,  if 
the  flaps  be  made  of  sufficient 
length  to  permit  of  the  forma- 
tion of  a  non-adherent  or  mov- 
able scar,  its  location  is  not  of 
great  importance.  In  fashion- 
ing flaps  it  is  well  to  remem- 
ber that  the  contractibility  of 
tissue  is  lessened  by  infiltra- 
tion of  inflammatory  prod- 
ucts, by  old  age,  and  by 
atrophy;  all  muscles  contract 
when  severed.  The  nutrition 
and  the  integrity  of  a  flap  are 
dependent  upon  its  artenal 
supply;  this  must  be  taken 
into  account  in  sectioning  the 
soft  parts.  Tendons  should 
not  be  permitted  to  extend  be- 
yond the  level  of  the  bone 
section.  The  nerves  should 
he  cut  higher  than  the  other  a 
soft  parts ;  failure  to  do  this  Fig. 

often  results  in  the  formation    «  and  h,  Double  edged  knives;   c,  d,  e,  single 

edged  knives  or  (liirerent  sizes. 
of    neuromata    in    the    scar, 

which    are   responsible    for   the   development    of    a    painful    stump. 

Laceration  of  the  periosteum  should  be  avoided.    The  hone  should  he 


bode 
406. —  Amputating  Knives. 


AMPUTATIONS 


863 


sawed  carefully  and  squarely,  care  being  taken  not  to  leave  spicula 
in  the  stump.  This  is  likely  to  happen  in  amputations  through  the 
leg  when  the  fibula  is  sawed  first  and  is  fractured  by  the  weight  of 
the  limb. 

Flaps  are  classified  in  accord  with  the  kind  of  tissues  the}'  comprise, 
as  cutaneous  (see  circular  method,  p.  874),  musculocutaneous  (see 
amputation  through  thigh  and  arm,  and  motor  stumps,  p.  875), 
osteoplastic  (see  Stokes,  p.  903),  and  periosteal  (see  circular  method, 
p.  874).  The  question  as  to  the  inclusion  of  muscle  in  the  flap  w^ould 
seem  answerable  in  the  following  way:  Muscular  tissue  always  atro- 
phies unless  it  function- 
V\  V.  ^n/ /  /  /  /       .  ates,  i.  e.,  it  disappears 

from  the  stump  unless 
it  is  concerned  in  mov- 
ing it ;  however,  as  it 
may  contain  blood  ves- 
sels capable  of  nourish- 
ing the  flap,  its  presence 
is  not  objectionable.  In 
fashioning  a  motor 
stump,  the  muscle  is 
destined  to  functionate 
and  is,  therefore,  pre- 
served; it  will,  however, 
soon,  disappear  unless  it 
is  given  duties  to  per- 
form, and  these  must  be 
imposed  at  the  earliest 
■  possible  moment.  Of 
course,  if  its  retention  in  the  stump  involves  the  danger  of  leaving  a 
pathological  process  in  situ,  it  should  not  be  preserved. 

Flaps  arc  fashioned  by  transfixation,  by  deep  division  from  without 
and  by  superficial  division  and  separation  of  the  tissues.  The  firet 
two  methods  provide  musculocutaneous  and  osteoplastic  flaps ;  the  last 
is  used  in  connection  with  tegumentary  flaps.  The  periosteal  flap  may 
be  employed  with  all  the  methods. 

The  methods  of  amputation  may  be  classified,  according  to  the  out- 
lines of  the  incision,  into  circidar,  modified  circular,  elliptical,  oval  or 
racket,  and  special  fiap  methods.  Each  of  these  is  described  below 
in  connection  with  the  amputation  of  special  parts. 


Fig.  407. —  Two  T^uled  Retractor  Applied. 


864    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


The  instruments  used  for  amputations  are  those  employed  for 
operations  on  bones  and  joints  (Figs.  332  and  333),  together  with 
special  amputation  knives  (Fig.  406)  and  retractors  (Figs.  407  and 
408),  The  various  agents  used  for  the  temporary  a7id  permanent 
arrest  of  hemorrhage  are  already  described  (p.  32). 

Amputating  knives  (Fig.  406)  (not  much  used  at  the  present  time) 
may  be  single  edged,  others  may  be  double  edged  (a  and  b)  entirely 
(Catlin)  or  only  for  an  inch  or  two. 

The  retractors  are  used  to  safeguard  the  soft  parts  as  the  bones 
are  sawed.  They  are  made  of  fabric,  have  two  or  three  tails,  and 
are  utilized  in  the  manner  shown  in  the  illustrations  (Figs.  407  and 
408). 

Amputation  of  the  Fingers. — Amputations  at  the  phalangeal  articul- 
lations  may  be  accom- 
plished by  any  of  the 
t  e  g  u  m  e  n  t  a  r  3'  flap 
methods,  i.  e.,  the  circu- 
lar, modified  circular, 
bilateral,  or  the  Teale 
method.  The  selection 
of  a  method  is  made  in 
accord  with  the  lesion. 
When  feasible  the 
palmar  flap  method 
(Fig.  409),  which  covers 
the  stump  with  skin 
normally  subjected  to 
pressure,  is  practiced. 
The    phalanx   is    flexed 

at  right  angles  with  the  central  one,  and  an  incision  Avhich  opens 
the  joint  is  made  on  the  dorsum  of  the  former,  on  a  line  corres- 
pondinrj  to  the  transverse  diameter  of  the  central  phcdanx.  The 
lateral  ligaments  are  divided  with  the  point  of  the  knife,  the  articular 
ends  of  the  bones  are  separated,  the  knife  passed  between  them  and 
carried  along  the  under  surface  of  the  phalanx  to  be  removed  close 
to  the  bone,  far  enough  forward  to  fashion  a  palmar  flap  of  sut^cient 
length  amply  to  cover  the  end  of  the  stump  (Fig.  409).  The  edge  of 
the  knife  is  then  turned  directly  downward,  so  that  the  full  thickness 
of  the  soft  parts  is  included  in  the  flap.  The  flexor  tendon  is  cut  level 
with  the  articular  surface  of  the  remainmg  phalanx ;  the  palmar  flap 


Fig.  408. —  Three  Tailed  liET::.\crcii  Applied. 


AMPUTATIONS 


865 


is  fixed  to  the  short  dorsal  one  with  two  silkworm  gut  sutures,  leaving 
ample  space  for  drainage,  and  the  protective  dressing  is  applied.  The 
sutures  are  removed  on  the  seventh  day. 

In  connection  with  amputations  of  the  second  and  third  fingers,  at 
the  metacarpophalangeal  articulation,  the  oval  flap  method  is  usually 
practiced.     The  flap  is  marked  out  before  the  operation  is  commenced 


Fig.  409. —  Amputations  in  the  Region  of  the  Fingers. 
Amputation  of  the  middle  finger  in  the  interphalangeal  joint;  opening  of  the 
joint  on  its  dorsal  side;  formation  of  a  palmar  flap  by  section  from  the  wound 
side  (note  angle  of  knife).  Racket  shaped  incision  for  enuclation  of  the  thumb 
at  the  metacarpophalangeal  joint.  Asymmetrical  anteroposterior  flaps  outlined 
on  the  index  finger. 

(Fig.  410).  The  flap  is  fashioned  from  the  integument  of  the  finger 
to  he  removed.  Centralh',  the  incision  corresponds  to  the  head  of  the 
metacarpal  bone,  its  lower  limit  (palmar  side)  crossing  the  transverse 
line  at  the  junction  of  the  palm  of  the  hand  with  the  corresponding  sur- 
face of  the  finger  (level  with  the  distal  limit  of  the  web).  The  adjacent 
fingers  are  v/idely  separated  (by  an  assistant)  ;   the  doomed  digit  is 


866     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

grasped  as  shown  (Fig.  410)  and  the  disarticulation  is  accomplished 
by  carrying  the  knife  (along  the  lines  of  the  preliminary  tegumentary 
incision)  into  the  deeper  parts,  as  indicated  in  Fig.  410.  If  cosmetic 
effect  is  to  dominate  the  situation,  the  head  of  the  metacarpal  bone 
may  be  removed  with  the  bone  forceps  (Fig.  411)  or  with  a  small  saw. 
The  resultant  oval  shaped  surface  is  closed  transversely  by  means  of 


Fig.  410. —  Amputating  Second  Finger  by  the  Oval  Flap  Method. 


two  silkworm  gut  sutures,  the  lower  (palmar)  aspect  of  which  is 
left  open  for  drainage,  and  the  protective  dressing  is  applied.  The 
sutures  are  removed  on  the  seventh  day.  /;;  the  presence  of 
infection,  the  wound  is  not  closed  at  this  time  but  is  loosely  tamponed 
with  iodoform  gauze  and,  when  the  inflammatory  process  has  sub- 
sided, secondary  repair  by  suture  (p.  61)  may  be  made  or  the  wound 
permitted  to  heal  by  granulation. 


AMPUTATIONS 


867 


The  thumh,  index  and  little  fingers  may  be  amputated  by  any  of 
the  methods  described;  it  is  desirable  that  the  flap  from  the  outer 
surface  of  the  index  finger,  from  the  inner  side  of  the  little  finger,  and 

from  the  palmar  side  of  the  thumb, 
be  slightly  longer  than  the  opposite 
one.  Fig.  412  shows  the  several 
types  of  amputation  used  at  the 
metacarpophalangeal  joints  of  the 
various  fingers.  However,  the  gen- 
eral rules  laid  down  above  may  be 
applied  to  cases  in  which  the  lesion 
does  not  permit  of  the  use  of  the 
methods   here    depicted.     For   in- 


FiG.  411. — Removal  of  the  Head  of  the 
Third  Metacarpal  Bone  of  Middle 
Finger. 


stance,  the  lines  of  incision  shown 
at  the  metacarpophalangeal  articu- 
lation of  the  index  finger  in  Fig. 
400  may  be  used  in  connection  with 
any  of  the  fingers. 

Amputation  of  the  thu))th,  little 
and  index  fingers  at  the  carpometa- 
carpal  articulation  may  be  accom- 
plished by  the  oval  method.  Fig. 
409  shows  the  lines  of  the  incision 
for  the  removal  of  the  thumh. 
Enucleation  of  the  metacarpal  bone 
does  not  present  any  technical  dif- 
ficulties ;  the  flaps  are  dissected 
back,  the  extensor  tendon  is  cut  at 

the  level  of  the  carpometacarpal  joint,  which  is  opened ;  the  bone  is 
dissociated  from  the  carpus  and  from  the  embedding  soft  parts  by 
means  of  an  elevator.     It  is  then  drawn  upward,  the  flexor  tendons 


Fig.  412. —  Flaps  in  Disarticu- 
lation of  Fingers. 
a.  Long  palmar  flap ;  6,  long  ex- 
ternal flap ;  c,  circular  method, 
dorsal  incision;  d,  lateral  flaps;  e, 
long  outer  flap. 


r 


868     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


are  cut  at  a  level  with  the  joint,  thus  separating  the  part  from  the 
hand.  The  residual  cavity  is  drained  with  ruhher  tissue  (Fig.  52) 
which  extends  from  its  carpal  end  to  its  distal  termination,  and  the 
wound  is  closed  with  silkworm  gut.  The  drain  ma}'  be  removed  in 
forty-eight  hours  (except  in  the  presence  of  infection)  and  the  sutures 
removed  on  the  seventh  day. 

The  little  finger,  together  with  its  metacarpal  hone,  may  be  enucle- 
ated by  a  racket  shaped  incision  such  as  is  shown  in  connection  with 
the  thumb  (Fig.  409)  ;  or  a  flap  from  the  ulnar  edge  of  the  hand  may  be 
fashioned  as  follows :  The  dorsum  of  the  hand  being  turned  toward 
the  operator,  the  fourth  and  fifth  fingers  are  widely  separated ;  the 
knife  enters  the  middle  of  the  web  between  the  fingers  (Fig.  413)  and 


Fig.  413.—  Exarticulation  or  the  Little  Finger  With  the  Metacarpus. 
Section  of  the  soft  parts  between  the  fourth  and  fifth  metacarpal  bones. 

advances  (with  a  sawing  motion)  to  the  root  of  the  hand.  The  fifth 
finger  is  now  strongly  abducted;  the  edge  of  the  knife,  which  is  now 
turned  toward  the  ulna,  divides  the  ligaments  at  the  base  of  the  meta- 
carpus ;  the  scalpel  is  then  swept  around  the  central  end  of  the  bone 
and  forms  a  flap  from  the  antithenar  aspect  of  the  hand  by  being 
carried  directly  forw^ard  (close  to  the  bone)  until  it  arrives  opposite 
from  where  it  started  (Fig.  414),  when  the  section  is  completed.  The 
wound  is  treated  in  the  manner  related  in  connection  with  removal 
of  the  thumb. 


AMPUTATIONS 


869 


The  index  finger,  together  with  its  metacarpus,  may  be  removed 
through  the  incision  shown  in  connection  with  a  similar  operation  upon 
the  thumb  (Fig.  409).  The  technic  of  the  procedure,  including  the 
care  of  the  wound,  does  not  varj'  in  any  essential  regard  from  that 
described  in  that  connection ;  indeed,  the  second  and  third  fingers, 
together  with  their  metacarpal  bones,  may  be  satisfactorily  enucleated 
in  this  way. 

In  some  instances  it  is  feasible  to  fashion  fingers  from  the  metacarpal 
bones.     Fig.  415  shows  the  result  in  a  ease  in  which  the  metacarpal 


Fig.  414. —  Exarticulation  of  the  Little  Finger  With  its  Metacarpal  Bone, 
Formation  of  the  musculocutaneous  flap  from  the  antithenar  aspect  of  the  hand. 

bones  of  the  middle  and  ring  fingers  were  removed  and  the  skin  folded 
around  those  of  the  index  and  little  fingers. 

Amputation  at  the  Wrist. —  As  far  as  the  formation  of  the  flaps  is 
concerned,  amputation  of  the  hand  through  the  carpometacarpel 
joints  does  not  differ  from  the  technic  employed  in  connection  with 
the  wrist  joint.  For  this  purpose,  a  long  palmar  and  a  short  dorsal 
flap  should  be  fashioned  if  possible. 

Disarticulation  at  the  icrist  may  be  accomplished  by  any  of  the 

methods    alluded    to    in    the    general    rules    governing    amputations 

(p.  863).     The  long  palmar  aiid  the  short  dc^rsal  flap  method  is  the 


I 


870    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


procedure  of  choice.  With  the  so-called  motor  stump  amputation 
shimmering  on  the  horizon,  it  is  not  improbable  that  a  method  of  this 
sort  applicable  to  the  region  of  the  wrist  will  soon  be  evolved ;  at  this 
writing  this  has  not  yet  (as  far  as  the  writer  knows)  been  done. 

At  the  wrist,  the  circular  (p.  874),  the  modified  circular  (p.  875), 
the  lo7ig  dorsal  (Teale, 
p.  895)  and  the  equal 
anteroposterior  (p.  877) 
may  be  employed.  Here 
the  lo)tg  palmar  and  the 
special  (DubrueiP)  will 
be  described.  However, 
when  the  motor  stump 
operation  arrives,  no 
doubt  the  modified  cir- 
cular flap  method  will  be 
employed  for  the  pur- 
pose. 

In  the  long  palmar 
flap  method  the  hand  is 
supinated,  the  wrist  is 
exteyided,  the  styloid 
processes  are  defined, 
and  the  thumb  is  ex- 
tended. The  palmar 
flap  is  fashioned  by  in- 
serting the  knife  at  the 
tip  of  the  styloid  process 
of  the  radius,  carrying  it 
straight  down,  well  on  to 
the  thenar  eminence, 
then  carrying  it  across 
on  a  level  with  the 
palmar  arch  and  mark- 
ing out  a  well  rounded 
flap  by  passing  over  the  hypothenar  eminence  to  the  tip  of  the  styloid 
process  of  the  ulna  (Fig.  416).  The  flap  is  dissected  up  off  the  flexor 
tendons  as  far  as  the  level  of  the  wrist  joint ;  it  should  include  some 
of  the  fibers  of  the  thenar  and  hypothenar  muscles  which  contain  the 
superficial  volar  and  the  ulnar  arteries. 


Fig.  415. —  Plastic  Utilization  of  Metacarpal 
Bones  for  Fingers  (Harlem  Hospital  ease). 


AMPUTATIONS 


871 


The  hand  is  now  pronated  and  flexed  at  the  wrist  joint,  and  a 
slightly  convex  incision  is  made  across  the  back  of  the  wrist  from  one 
styloid  process  to  the  other;  this  involves  the  skin  and  subcutaneous 
tissue  only.  The  palmar  flap  is  now  retracted,  the  hand  is  strong!}- 
flexed  and  the  joint  opened;  the  soft  parts  in  front  and  behind  are 
severed  with  a  sweep  of  the  knife ;  the  remaining  ligaments  are 
divided  and  the  exarticulation  is  completed.  The  styloid  processes 
are  always  removed;  however,  the  hase  of  that  of  the  radius  should 
he  spared  with  the  view  of  preserving  the  insertion  of  the  supinator 

longus  muscle.  The  radial,  the  ulnar, 
the  two  interosseous  and  the  super- 
ficial volar  are  tied. 

A  drainage  tuhe  is  placed  trans- 
versely across  the  face  of  the  bones; 
the  edge  of  the  palmar  flap  is  apposed 
to  that  of  the  short  dorsal  with  inter- 
rupted silkworm  gut  sutures,  leaving 
the  ends  of  the  drainage  tube  protrud- 
ing from  either  side  in  the  manner 
shown  in  Fig.  418.  The  protective 
dressing  is  applied  and  the  forearm  is 
placed  on  a  splint.  The  drainage  tube 
is  removed  on  the  third  day,  the 
sutures  on  the  tenth  day.  The  stump 
is  a  very  useful  one.  In  the  presence 
of  infection,  the  wound  is  tamponed 
with  iodoform  gauze  and  a  secondary 
repair  b}'  suture  is  made  (p.  61). 

DiibrueiVs^  method  of  amputating 
at  the  wrist  is  employed  when  the 
lesion  involves  the  entire  hand  and 
the  extensor  aspect  of  the  thumb  is 
unimpaired.  Unfortunately,  these  conditions  are  not  often  met  with 
and  the  operation  of  relief  must  be  performed  through  the  forearm. 
However,  its  technic  is  instructive  in  its  bearing  upon  amputations 
generally. 

The  hand  being  pronated,  the  knife  sections  the  skin  and  subcuta- 
neous tissues  by  beginning  at  a  point  at  the  junction  of  the  outer  and 
middle  thirds  of  the  back  of  the  forearm,  a  little  below  the  wrist  joiiit, 
and  forming  a  convex  flap,  the  summit  of  which  corresponds  to  the 


Fig.  41 6. —  Octlixe  of  Flap  m 
THE  Long  Palmar  Flap  Method 
of  disakticulation  through  the 
Wrist  Joint. 


872     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


middle  of  the  dorsal  surface  of  the  thumb  and  termiuates  in  front, 
just  below  the  palmar  aspect  of  the  wrist  at  a  point  opposite  to  its 
beginnmg.  This  tlap  is  raised  and  the  two  ends  of  its  base  are  con- 
nected by  an  incision  at  a  right  angle  to  the  long  axis  of  the  forearm. 
The  outline  of  the  incision  is  shown  in  Fig.  417.  The  exarticulation 
is  accomplished  from  the  radial  side  of  the  joint,  though  this  may  be 
reversed.     The  styloid  processes  are  removed,  care  bemg  taken  to  save 

the  insertion  of  the  supinator 
longus  into  the  base  of  the  radial 
process. 

The  flap  from  the  radial  side 
of  the  hand  is  adjusted  in  the 
manner  shown  in  Fig.  418.  In- 
terrupted silkworm  gut  sutures 


Fig.  417. —  Outline  op 
Incision  in  Dubreuil's 
Amputation  through 
THE  Wrist  Joint. 


Fig.  418. —  Dubreuil's 
Amputation  Completed; 
Drainage  Tube  in  Situ. 


are  used  to  allow  of  the  introduction  of  a  drainage  tube  and  in  order 
that  (if  necessary)  alternate  sutures  may  be  removed  during  the  after 
treatment  without  causing  complete  displacement  of  the  flap.  The 
drainage  tube  is  drawn  through  the  wound  with  forceps  after  the  flap 
is  sutured  and  is  placed  so  that  its  long  axis  corresponds  to  the  position 
of  the  forearm  (when  the  latter  is  in  a  sling),  which  enhances  depen- 
dent drainage.  The  after  treatment  is  the  same  as  that  following 
the  long  palmar  flap  method  (p.  871). 
Amputations  at  or  just  above  the  wrist  may  be  supplemented  by  the 


AMPUTATIONS 


873 


so-called  * '  lobster  claw ' '  method.    After  the  radius  and  ulna  are  separ- 
ated (Fig.  419A)  the  former  is  capable  of  independent  motion  (mov- 


FiG.  419. —  "LoBSTEK  Claw"  Plastic  Amputation  at  Lower  Forearm. 
A,  Primary  separation  of  radius  and  ulna;  the  radial  jaw  is  covered  by  folding 
the   skin    around   it.     B,    Dermoplastic    repair    of   ulnar    jaw    of   claw.      C,    The 
"lobster  claw"  in  use  (Krukenberg). 

able  portion  of  the  claw),  while  the  ulna  acts  in  a  passive  capacity. 
Thus,  the  musculature  of  the  radius  (which  is  preservable)  is  capable 
of  separating  or  approximating  the  two  bones  of  the  forearm  at  will : 


874     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

i.  e.,  the  radius  acts  like  a  thumb.  The  supinator  brevis,  the  brachialis 
anticus,  and  the  two  extensores  carpi  radialis  abduct  the  radius  (open 
the  claw).  The  pronator  teres  and  the  flexor  carpi  radialis  adduct 
the  radius  (close  the  claw).  The  defect  on  the  medial  side  of  the 
lower  sector  of  the  claw  (ulna)  is  covered  with  a  dermoplastic  flap 
from  the  upper  abdomen  (Fig.  419B).  Fig.  419C  shows  the  ''claw" 
in  use. 

Amputations  through  the  Forearm. —  Amputations  through  the  fore- 
arm may  be  performed  by  the  anteroposterior  with  circular  division 
of  muscles;    hy  transfixion;    the  circular,  Teale's;    and  the   motor 


Fig.  420. —  Dissecting  up  the  Skix  and  Subcutaneous  Tissues  in  the  Circulab 

Integumentary  Cuff  Method. 

Note  that  the  cutting  edge  of  the  knife  is  directed  toward  the  muscle. 

stump  method.  The  circular,  the  modified  circular,  and  the  motor 
stump  method  will  be  described  here.  The  transfixion  method  is  no 
longer  employed  in  this  situation.  The  part  is  prepared  in  the  usual 
way  (p.  86). 

The  circular  tegumentary  flap  method  is  fashioned  as  follows :  Bear- 
ing in  mind  the  rule  as  to  the  combined  length  of  the  flaps  (p.  861), 
the  cuff  (being  really  two  flaps  in  one)  is  made  slightly  longer  than, 
one  fourth  the  circumference  of  the  limb  at  the  point  of  bone  section ; 
a  circular  incision  is  made  through  the  skin  and  subcutaneous  tissues 
and  the  cuff  dissected  up  by  means  of  repeated  incisions  directed 


AMPUTATIONS 


875 


toward  the  muscles  (Fig.  420).  If  difficulty  is  experienced  in  turning 
up  the  cuff,  it  is  slit  on  either  side  and  the  amputation  then  becomes 
a  modified  circular;  or,  if  terminology  is  to  be  served,  it  becomes  an 
anteroposterior  tegumentary  flap  method;  if,  because  of  the  asym- 
metry of  the  lesion,  it  is  necessary  that  one  of  the  sides  of  the  slitup 
cuff  must  be  made  longer  than  the  other,  the  amputation  may  be  said 
to  be  done  by  the  bilateral  unequal  flap  method.  In  any  event,  the 
flap  or  flaps  thus  formed  are  reflected  over  the  central  end  of  the 
forearm  and  the  muscles  divided,  one  half  inch  below  the  line  of  reflec- 
tion, with  a  sweep  of  the  knife  (Fig.  421)  (a  scalpel  may  be  used). 
The  undivided  tissues  between  the  bones  are  severed  with  a  slender, 
double  edged  knife  (Fig.  406  a  and  b),  the  muscles  are  drawn  upward 


Fig.  421. —  Dividing  the  Muscles  in  a  Circular  Amputation. 
The  knife  is  held  so  as  not  to  injure  the  flap. 

with  a  three  tailed  retractor  (Fig.  408),  and  the  bones  are  sawed  at 
the  highest  point,  the  radius  being  divided  first.  The  radial,  the 
ulnar,  and  the  anterior  and  posterior  interosseous  arteries  are  tied, 
bleeding  from  minor  blood  vessels  is  arrested,  and  the  skin  flaps 
apposed  with  interrupted  silkworm  gut  sutures.  The  stump  is  drained 
in  much  the  same  way  as  shown  in  Fig.  418.  After  the  protective 
dressing  is  applied  the  stump  is  placed  on  a  splint.  The  drainage 
tube  is  removed  on  the  third  day  (except  in  the  presence  of  infection) 
and  the  sutures  on  the  tenth  day. 

The  Motor  Stump. —  At  the  forearm  a  motor  stump  has  been  fash- 
ioned by  the  single  and  by  the  double  motor  metJiod.  Gaudiani  (who 
gives  an  excellent  review  of  the  subject,  see  bibliography)  in  a  per- 
sonal communication  to  the  writer  states  that  most  surgeons  have  not 


876     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

found  the  double  motor  plan  satisfactory  in  this  situation  —  a  view 
with  which  the  writer  is  inclined  to  agree.  Only  the  single  motor  is 
described  here.  Gaudiani^  credits  Vanghetti^  with  the  original 
experimental  work  and  Von  Wreden^  and  De  Francesco*'  with  the 
first   successes   in   this   connection.      Gaudiani^   divides   the   problem 


Fig.  422. —  Fashioning  of  a  Motor  Loop  Stump  at  the  Forearm. 

A,  Transverse  section  of  the  forearm   (Celsus)  ;   lateral  sections  made. 

B,  Two  flaps  formed ;  bones  sawn. 


into  two  parts,  the  primary  and  the  secondary  motor  stump. 
The  former  means  that  a  motor  stump  is  fashioned  when  the 
part  is  removed  for  relief  of  the  lesion ;  the  latter  refers  to  fashion- 
ing a  motor  stump  from  one  resulting  from  the  ordinary  methods  of 
amputation.     He  suggests  that,  when  feasible,  the  primary  amputation. 


AMPUTATIONS 


877 


should,  ill  all  instances,  be  performed  in  a  manner  which  will  make 
possible  the  fashioning  of  a  secondary  motor  stump  at  a  later  date. 
This  would  seem  to  be  especially  applicable  in  cases  in  which  the 
surgeon  is  not  certain  of  how  much  sloughing  and  necrosis  will  follow 
the  primar}'  amputation. 

Through  the  forearm,  the  fashioning  of  a  motor  loop  as  suggested 
by  Fieri"  has  resulted  in  the  formation  of  a  .stump  which  is  capable  of 


D 

Fig.  422. —  Fashioning  of  a  Motor  Loop  Stump  at  the  Forearm. 

C,  Apposition  of  the  skin  enfolding  the  tendons. 

D,  The  two  sectors  approximated,  forming  the  motor  loop. 

flexing  the  fingers  of  an  artificial  hand,  extension  being  taken  care  of 
by  the  mechanism. 

The  forearm  is  sectioned  as  in  the  old  operation  of  Celsus,  and  two 
lateral  incisions,  one  over  the  lateral  aspect  of  the  radius,  the  other 
over  that  of  the  ulna,  are  made  (Fig.  422A),  thus  forming  two  antero- 
posterior musculocutaneous  flaps;    these  are  dissected  up   and   the 


878      INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

bones  are  sawed  at  a  level  with  the  central  ends  of  the  lateral  incisions 
(Fig.  42B).  The  integumentary  coverings  of  the  flaps  are  apposed 
over  their  greatest  extent  as  shown  in  Fig.  422C,  and,  finally,  the  two 
ends  of  the  soft  parts  are  brought  together  in  the  center  as  shown  in 
Fig.  422D,  thus  forming  a  loop  which  contains  muscle  tissue,  tendons, 
nerves  and  blood  vessels,  and  which  is  capable  of  responding  to  motor 


13 

Fig.  423. —  Artificial  "Broad  Grasp"  Hand  Animated  by  Motor 

Loop  Stump  op  Forearm. 

A,  Hand  open.     B,  Hand  closed. 

impulses  governed  by  the  will.     The  mode  in  which  the  loop  acts  is 
shown  in  Fig.  423  A-B. 

The  After  Care  is  Important . — In  order  to  prevent  retraction  and 
atrophy,  a  strand  of  fabric  is  passed  through  the  loop  (while  healing 
is  going  on),  brought  out  through  the  dressing  and  a  weight  attached 
to  its  end,  the  patient  attempting  to  lift  light  weights  in  this  way  as 


AMPUTATIONS 


879 


soon  as  possible.  Adhesive  plaster  may  be  attached  to  the  limb  above 
the  loop  and  tractiou  made  on  the  soft  parts  as  with  Buck's  extension 
(p.  739).  Massage  and  exercises  are  begun  as  soon  as  the  condition 
of  the  wound  permits.  Efforts  have  been  made  to  overcome  the  tend- 
ency toward  retraction  by  complicated  osteoplastic  procedures  within 
the  stump.  These  have  not,  as  yet,  been  performed  sufficiently  often 
to  warrant  a  conclusion  as  to  their  practicability.  However,  the  near 
future  should  develop  something  in  this  connection,  especially  as  the 
behavior  of  bone  grafts  is  now  so  much  better  understood  (p.  801). 
Additional  information  may  be  obtained  by  consulting  the  bibliog- 
raphy, as  collected  by  Gaudiani.^ 

Amputation  at  the  Elbow.— Disarticulation  at  the  elbow  may  be 
accomplished  by  the  circular,  modified  circular  (p.  875),  long  posterior 
and  short  anterior  or  long  anterior  and  short  posterior  flap  methods. 


^^  :\\\#W- -■"% 


Fig.  424. —  Outline  op  Flaps  for  Disarticulation  at  the  Elbow  Joint 
BY  the  Long  Anterior  and  SiiortPosterior  Musculocutaneous  Flap 
Method. 


Of  these,  the  circular  and  modified  circular  do  not  involve  factors 
not  considered  in  connection  with  amputation  of  the  forearm.  The 
long  posterior  and  short  anterior  do  not  differ  from  the  reverse 
in  any  essential  particular;  it  is  only  necessary  for  the  surgeon  to 
rcA'^erse  the  incisions.  In  fashioning  the  circular  and  modified  cir- 
cular flaps,  the  integument  and  subcutaneous  tissues  only  are  utilized. 

In  the  long  anterior  and  short  posterior  musculocuta^ieous  flap 
method,  the  relative  lengths  of  the  flaps  are  varied  in  accord  with  the 
nature  and  the  site  of  the  lesion.  It  is  necessary,  of  course,  to  bear 
in  mind  the  general  rule  in  this  connection.  Many  of  the  older  sur. 
geons  perform  this  amputation  by  traiLsfixion,  and  this  is  permissible ; 
however,  the  tissues  are  cut  with  greater  accuracy  with  the  scalpel. 
The  flaps,  as  indicated  in  Fig.  424,  are  outlined  and  the  knife  carried 
obliquely  downward  and  upward  to  the  anterior  surface  of  the  bones 


880     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


aud  the  flap  dissected  up  to  the  joint.  The  posterior  flap  is  then 
dissected  up  to  a  level  with  the  tip  of  the  olecranon.  The  knife  again 
enters  the  anterior  wound  and  dissociates  the  bones  by  severing  the 
ligaments  of  the  joint;  an  assistant  holds  the  flaps  aside  while  the 
surgeon  makes  traction  on  and  rotates  the  forearm  with  one  hand  and 
finishes  the  section  with  the  other  (Fig.  425).  A  quarter  inch, 
fenestrated  drainage  tube  (Fig.  48)  is  placed  transversely  into  the 
wound  in  the  manner  shown  in  connection  with  Dubrueil's  amputation 
at  the  wrist    (Fig.  418)    and  the  flaps  apposed  with  silkworm  gut 


Fig.  425. 


•Disarticulation  at  the  Elbow  Joint  by  the  Long  Anterior  ane> 
Short  Posterior  Musculocutaneous  Flap  Method. 


sutures.  The  insertion  of  two  retention  sutures  which  transfix  the 
flaps  and  are  tied  over  gauze  or  threaded  through  buttons  (Fig. 
39)  is  advisable.  In  the  presence  of  infection,  the  two  retention 
sutures  only  are  introduced  and  the  rest  of  the  flap  area  lightly  tam- 
poned with  gauze  (the  tube  is  omitted)  ;  secondary  suture  repair 
may  be  made.  In  clean  cases,  the  tube  is  removed  on  the  third  day, 
the  sutures  on  the  tenth  daj^  The  muscle  tissue  ultimately  atrophies ; 
however,  the  stump  is  likely  to  be  a  very  satisfactory  one. 


AMPUTATIONS 


881 


Amputations  through  the  Arm. —  In  amputating  through  the  arm, 
the  circular,  modified  circular  (p.  875),  or  the  anteroposterior  (p.  875) 
tegumentary  flap  methods  may  be  employed.  In  the  latter  instance, 
the  longer  flap  may  be. fashioned  from  either  aspect  of  the  arm. 
Teale's  method  (p.  895)  is  rarely  used. 

For  the  purpose  of  forming  a  sinrjle  motor  stump  (the  double  motor 
stump  is  not  satisfactory)',  Sauer- 
bruch,*  using  the  technic  evolved 
by  Putti,''  makes  a  circular  ampu- 
tation and  canalizes  the  biceps 
muscle,  as  shown  in  Fig,  426.  The 


B 


C 

Fig.  426. —  Canalizatiox  of  Upper  Ar:m  Stuiip. 
A,  Formation  of  a  dermal  tube.    B,  Dermal  tube  being  drawn  through  muscle 
canal.    C,  Suture  of  the  dermal  tube.    D,  Closure  of  the  skin  defect. 

manner  in  which  the  stump  is  capable  of  traction  is  shown  in  Fig.  427. 
The  after  treatment  is  the  same  as  that  described  in  connection  with 
the  single  motor  loop  stump  (p.  878). 

Amputation  at  the  Shoulder. —  Disarticulation  at  the  shoulder  joint 
is  accomplished  by  several  methods,  all  of  which,  however,  consist  in 
the  application,  to  this  situation,  of  procedures  already  described  in 


882     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

connection  with  amputations  of  other  parts.  A  study  of  the  so-called 
Kocher  method  shows  it  to  be  very  similar  to  the  long  palmar  and 
short  dorsal  flap  described  in  connection  with  ablation  of  the  hand  at 
the  wrist  joint.  The  racket  shaped  method  proves  to  be  similar  to 
that  employed  for  removal  of  the  thumb  at  the  carpometacarpal 
articulation,  and  so  on.  As  it  is  regarded  as  an  essential  part  of  the 
educational  equipment  of  the  surgeon  to  be- familiar  with  the  names 
applied  to  some  of  the  methods  (similar  as  they  are  in  principle  to 
those  already  taken  up),  the  incisions  of  two  are  depicted  in  Fig. 
428.  The  text  is  restricted  to  a  description  of  the  method  of  Spence, 
which  may  be  modified  to  meet  anj-  condition.  Jacobson^''  says 
that  thirty-six  different  methods  of  disarticulation  at  the  shoulder 


Fig  427. —  Single  Motor  Stump  of  Arm  With  Ivory  Kod  and  Silk 
String,  Which  Animates  the  Artificial  Hand  Shown  in  Fig.  423. 

joint  are  described  in  the  literature.  He  sees  no  reason  why 
the  general  principles  which  govern  amputations  generally  should 
not  be  applied  here.  He  indicates  that  "disarticulation  by  the 
Spence,  the  lateral  skin  flaps  or  the  en  racquette  methods  is  far  pref- 
erable, as  each  of  these  allows  of  securing  the  artery  before  it  is  cut, 
of  exploring  the  condition  of  the  head  of  the  bone,  and  permits  of 
making  one  flap  longer  than  the  other  according  to  the  indications." 

Special  metJiods  of  controlling  hemorrhage  are  employed.  Digital 
pressure  on  the  subclavian,  in  which  the  thumb  compresses  the  arterj'- 
against  the  first  rib,  is  not  entirely  satisfactory,  though  it  undoubtedly 
lessens  bleeding.  Direct  compression  of  the  artery  with  the  hands, 
by  grasping  the  tissues  before  they  are  cut,  controls  the  bleeding  in  all 


AMPUTATIONS 


883 


instances  (Fig.  430).  A  combination  of  the  elastic  exsanguination  of 
V.  Esmarch  and  the  employment  of  Wyeths  pins  (Fig.  429)  is  largely 
used.  The  limb  is  exsanguinated,  as  far  as  is  possible,  by  means  of 
the  V.  Esmarch  bandage  (Fig.  12).  Two  large,  heavy,  especially 
constructed  pins  are  introduced  in  the  manner  shown  in  Fig.  429  and 
the  elastic  constriction  caused  to  encircle  the  girdle  of  the  shoulder 
above  them  (Fig.  429)  ;  the  pins  are  intended  to  keep  the  constrictor 
from  slipping. 

Spence's'^^  method  (Fig.  428)  is  executed  as  follows:     The  arm  is 


B 

Fig.  428. —  Amputation  at  the  Shoulder  Joint. 
A,  Larry's  incision.     B,  Spence's  incision. 


.'■..J 


Ml 


slightly  abducted  and  rotated  outward.  The  knife  incises  the  soft 
parts  down  to  the  head  of  the  bone,  at  a  point  immediately  external 
to  the  ccracoid  process,  and  is  carried  downward  through  the  fibers 
of  the  deltoid  and  pectoralis  major  to  the  lower  border  of  the  latter 
(this  is  practically  the  same  incision  employed  in  arthrotomy  in  this 
situation  (p.  815)  and  constitutes  one  of  the  advantages  of  the  method, 
as  it  gives  the  surgeon  an  opportunity  to  proceed  with  the  exarticula- 
tion  or,  if  the  conditions  thus  uncovered  warrant  it,  to  direct  his  meas- 
ures of  relief  to  an  arthrotomy,  arthrectomy,  etc.)  which  is  divided. 


884     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


The  incision  is  then  carried  with  a  gentle  curve  outward,  across  and 
through  the  lower  fibers  of  the  deltoid  to,  but  not  through,  the  pos- 
terior border  of  the  axilla  (Pig.  428),  The  inner  incision  begins  at 
the  lower  extremity  of  the  vertical  one  and  is  carried  around  the  inner 
side  of  the  arm  through  the  skin  and  subcutaneous  tissues  only,  and 
meets  the  termination  of  the  other.  The  fibers  of  the  deltoid,  together 
with  the  posterior  circumflex  artery,  may  now  be  separated  from  the 
head  of  the  bone  and  the  joint  and  are  readily  drawn  backward  and 
out  of  the  way.    The  ligaments  and  muscular  attachments  are  divided ; 


HI  ii;o,,,, 


Fig.  429. —  Temporary  Control  of  Bleeding  by  Means  of  Wyeth's  Pins. 

Pins  and  elastic  constrictor  in  position.  The  v.  Esmarch  bantlaj?;e  has  been 
removed  from  the  arm.  Tlie  knots  on  the  ends  of  the  pins  protect  the  surgeon's 
hands  during  the  oijeration. 

disarticulation  is  accomplished  and  the  muscles  and  large  vessels  on 
the  inner  side  of  the  arm  (still  intact)  are  separated,  from  the  hone 
from  above  downward.  The  assistant  grasps  the  soft  parts  last  men- 
tioned with  the  hands  (Fig.  430),  thus  absolutely  controlling  the 
bleeding,  and  the  surgeon  completes  the  section  from  within  outward, 
using  the  superficial  incision  as  a  guide  (Fig.  430).  This  is  a  most 
desirable  manner  of  controlling  the  bleeding  and  makes  the  employ- 
ment of  a  constrictor,  as  shown  in  Fig.  429,  unnecessary.  The  latter 
may  be  used  in  the  absence  of  reliable  assistance. 


AMPUTATIONS 


885 


A  quarter  inch,  fenestrated  rubber  drainage  tube  is  introduced 
into  the  residual  cavity  and  the  wound  sutured  as  shown  in  Fig. 
431.  The  tube  is  removed  on  the  third  day,  the  sutures  on  the 
tenth  day.  Although  the  muscle  tissue  ultimately  atrophies,  its 
temporary-  presence  assures  a  plentiful  blood  supply  to  the  flap  and 
contributes  to  the  preservation  of  the  contour  of  the  shoulder.  The 
stump  is  not  well  adapted  to  the  adjustment  of  a  prosthesis. 

It  is  interesting  to  note  that,  when  exarticulation  at  the  shoulder 

joint  is  begun  with 
the  vertical  in- 
cision described  in 
connection  with 
the  Spence  method, 
the  subsequent 
steps  of  the  opera- 
tion may  follow 
those  described  in 
connection  with 
other  methods.  The 
incision  maybe  car- 
ried in  a  curve 
around  the  lower 
portion  of  the  del- 
toid muscle  and  up 
to  the  superior  pos- 
terior aspect  of  the 
axilla ;  the  flap  thus 
formed  may  be  dis- 
sected up,  the  hum- 
erus disarticulated, 
and  a  short  U- 
shaped  flap  fash- 
ioned on  the  inner 
side  of  the  arm.  The  operation  may  then  be  called  a  bilateral  musculo- 
cutaneous flap  amputation.  If  need  be,  the  incision  may  be  extended 
downward  and  a  long  flap  fashioned  from  the  inner  side  of  the  arm  and 
a  short  one  from  the  outer  aspect ;  these  may  consist  of  skin  and  fat 
only,  or  may  include  muscle  tissue.  If  the  lesion  involves  an  extensive 
portion  of  the  axilla,  so  that  its  tissues  and  those  of  the  inner  side  of  the 
arm  together  with  the  humerus  must  be  completely  sacrificed,  a  long 


Pig.      430. —  Spencer's      Disarticulation      at     the 
Shoulder  Joint. 
The    humerus    is   delivered.      The  knife    is    about   to 
divide  the  muscles,  arteries  and  other  soft  parts  behind 
the   humerus. 


886     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


external  flap  may  be  fashioned  from  the  outer  aspect  of  the  arm,  the 
latter  being  sutured  to  the  edges  of  the  denuded  surface  and  the 
method  resolves  itself  practically  into  a  single  flop  method.  In  each  of 
these  methods,  when  feasible,  the  division  of  the  blood  vessels  is  left 
until  the  last  and  they  are  controlled  in  the  manner  indicated.  In  the 
presence  of  infection,  the  wound  area  may  (like  all  wounds)  be  loosely 
tamponed  with  iodoform  gauze  and  a  secondary  apposition  of  the  flap 
or  flaps  made  by  suture  when  repair  is  manifest.  If  this  is  done,  two 
or  three  retention  sutures  may  be 
introduced  thi'ough  the  entire 
thickness  of  the  flaps  and  tied 
over  plugs  of  gauze.  The  per- 
sistent reiteration  of  the  advice 
regarding  ligJit  tamponade  of 
amputation  wounds  with  iodoform 
gauze  is  based  on  the  observation 
that  nothing  else  so  far  devised 
meets  the  situation  as  satisfac- 
torily, provided  the  tamponade 
permits  of  the  ready  discharge  of 
wound  secretions,  and  the  protec- 
tive dressing  is  so  arranged  as  to 
allow  of  the  entrance  of  oxygen  to 
the  wound  (p.  72). 

The  interscapulothoraeic  ampu- 
tation is  usually  accomplished  by 
the  method  generally  ascribed  to 
Paul  Berger.^^  Formidable  as 
the  procedure  appears,  Kocher^^  -pm.  431.— Appearance  of  Stump 
quotes  Buchanan   as  placing  the       After     Spence's     Disarticulation 

,    T,  •  .         -innn  i.  AT  THE   SHOULDER   JoiNT. 

mortality,    previous   to    1900,    at       mi      ^       •        ^      :,     j.^.     ^    • 

•"    ^  The    flap    i3    sutured ;    the    drainage 

only  sixteen  per  cent.    As  prophy-  tube  is  in  place, 
lactic    hemostasis    is    not    prac- 
ticable, the  first  measure  is  directed  toward  ligature  of  the  large 
vessels.    As  in  all  prescribed  methods,  the  skin  incisions  are  suscep- 
tible of  modification.     The  lines  of  incision  in  Berger's  method  are 
depicted  in  Fig.  432. 

An  incision  is  made  from  the  sternal  to  the  acromion  end  of  the 
clavicle.  The  periosteum  of  the  clavicle  is  split,  the  bone  is  sectioned 
at  its  inner  third,  the  outer  two  thirds  are  forcibly  pulled  outward  and 


AMPUTATIONS 


887 


TRANSfCRUS  COUI   AfirtKV 


Tig.   432. —  Anatomical   Preparation   of  Berger's   Shoulder  Girdle 

Amputation. 


separated  from  the  posterior  portion  of  the  periosteum  and  subclavius 
muscles.  The  trapezius  muscle  is  also  separated  from  the  upper  aspect 
of  the  clavicle  and  from  the  acromion.  When  the  subclavius  muscle 
and  the  fascia  are  opened,  the  subclavian  artery  and  vein  and  the 
brachial  plexus  are  exposed.  The  nerves  are  sectioned,  the  vessels  are 
doubly  lig'ated  and  divided.  Bleeding  may  be  reduced  to  a  minimum 
if,  at  this  time,  the  following  branches  of  the  subclavian  artery  (which 
are  readily  accessible)  are  tied:  The  ascending  cervical,  the  super- 
ficial cervical,  the  transversus  scapulae,  and  the  transversalis  colli. 
The  incision  is  now  extended  along  the  anterior  border  of  the  axilla 
(Fig.  432),  dividing  the  pectoralis  major  and  minor  muscles  close  to 
the  thorax,  thus  exposing  the  anterior  surface  of  the  scapula  from  the 


INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


front.  The  arm  is  rotated  outward  and  the  levator  scapulae  is  divided 
close  to  its  insertion;  the  serratus  niagnus  and  the  rhomboid  muscles 
are  sectioned  close  to  the  median  edge  of  the  scapula.  The  scapula  is 
rotated  sharply  outward  and  the  trapezius  and  the  omohyoid  muscles 
are  separated  from  the  crista.  The  skin  is  sectioned  (dotted  line, 
Fig.  432)  from  within,  at  a  point  which  makes  certain  that  the  residual 
wound  will  be  amply  covered.  The  measure 
is  accomplished  with  but  little  loss  of  blood. 
Berger^^  lays  especial  stress  on  ligature  of  the 
branches  of  the  subclavian  artery  as  stated. 
LeConte,^*  Langenbeck,^^  and  Ollier^^  remove 
the  clavicle  in  its  entirety,  on  the  ground  that 
the  vessels  are  thus  made  more  readih"  access- 
ible. Keen^"  submits  an  exhaustive  study  of 
the  problem  and  Russel  Fowler^^  also  presents 
interesting  data  in  this  connection.  The 
wound  is  drained,  as  after  Spence's  exarticu- 
lation,  through  the  shoulder  joint  (p.  884). 

Amputation  of  the  Toes. —  The  technic  of 
amputation  of  the  toes  does  not  differ  from 
that  employed  in  connection  with  amputation 
of  the  fingers. 

Amputation  at  the  Ankle. —  Disarticulation 
through  the  tarsometatarsal  joint  may  be  ac- 
complished by  any  of  the  methods  discussed 
above.  The  method  most  frequently  employed 
is  that  of  Lisf  ranc ;  it  is  very  similar  to  the  long 
palmar  and  short  dorsal  flap  method  de?^cribed 
in  connection  with  the  wrist  joint  and,  for  the 
same  reasons  (p.  869),  is  regarded  as  the 
method  of  choice.  For  elucidation  of  the  older, 
more  or  less  spectacular  method  of  accomplish- 
ing the  purpose  the  reader  is  referred  to 
Bryant,^  Jacobson  and  Stewart,^°  etc. 

The  technic  employed  at  the  present  time  is  as  follows :  A  plantar 
flap  is  fashioned  b}^  introducing  the  knife  into  the  sole  of  the  foot  at 
the  outer  edge  of  the  base  of  the  fifth  metatarsal  bone  and  carrying  it 
along  the  outer  edge  of  the  foot  to  the  head  of  the  same  bone  (base  of 
the  small  toe),  incising  the  skin  and  subcutaneous  tissues  (which  are 
very  dense)  ;    thence  in  a  gentle  curve   (convexity  forward)   to  the 


Fig.  433. —  Foot  Ampu- 
tations. 
A,  Outline  of  plantar 
flai5  in  Lisf  ranc 's  tarso- 
metatarsal disarticula- 
tion. B,  Outline  of 
plantar  flap  in  Chopart's 
mediotarsal  disarticula- 
tion. C,  Outline  of  plan- 
tar incision  in  the  Rynie 
and  the  Pirogoff  ampu- 
tations. 


AMPUTATIONS 


889 


base  of  the  great  toe  and  backward  along  the  inner  aspect  of  the  sole 
of  the  foot  to  a  point  opposite  to  its  beginning,  or  vice  versa  (Fig. 
433)  ;  this  flap,  consisting  of  skin  and  subcutaneous  tissue,  is  dis- 
sected up  to  its  full  extent.  The  foot  is  now  extended  and  an  incision 
is  made  across  its  dorsum,  which  connects  the  upper  ends  of  the 
plantar  incision  and  is  slightly  curved  downward  so  as  to  form  a  short 
flap  consisting  of  skin  and  subcutaneous  tissue.     This  is  dissected 


Tig.  434. —  Appearance  of 
Flap  ix  Lisfranc's  Ampu- 
tation. 


Fig.     435. —  Completed     Lisfranc  's 
Amputation. 
The  flap  is  sutured;  drainage  tube 
in  place. 


upward  and  the  deeper  tissues  (tendons,  nerves,  and  vessels)  are 
divided ;  the  joint  between  the  cuboid  and  the  fifth  metatarsal  bone  is 
opened  and  the  three  cuneiform  and  the  remaining  four  metatarsal 
bones  are  separated,  bearing  in  mind  that  the  articulation  between 
the  second  metatarsal  and  the  middle  cuneiform  bone  is  placed  higher 
than  those  on  either  side  and  that  the  inner  of  the  four  joints  is  some- 


890     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


what  nearer  the  toes  than  the  outer.  The  deep  tissues  of  the  sole  of 
the  foot  are  divided  on  a  level  with  the  upper  end  of  the  plantar  flap, 
and  are  removed  with  the  toes  and  the  metatarsal  bones.  This  leaves 
a  condition  of  affairs  as  shown  in  Fig.  434.  A  quarter  inch,  fene- 
strated rubber  drainage  tube  is  placed  transversely  across  the  face  of 
the  tarsal  bones  and  allowed  to  protrude  from  either  side  of  the  wound 
(Fig.  435),  and  the  plantar  flap  is  turned  upward  and  sutured  to  the 
dorsal  with  interrupted  silkworm  gut  sutures  (Fig.  435),  The  tube 
is  removed  on  the  third,  and  the  cutures  on  the  tenth,  day  after  the 
operation. 

Chopart's  amputation,  through  the  mediotarsal  joint  involves  the 
loss  of  the  insertion  of  the  tibialis  anticus  muscle  and  is  followed  by  a 
so-called  "pointed  stump."  "While 
this  may  perhaps  be  overcome  by 
fastening  the  tendon  of  the  muscle  to 
the  inner  aspect  of  the  talus,  the  out- 
come of  the  measure  is  doubtful.  In 
addition  to  this,  the  stump  does  not 
permit  of  the  application  of  an  effec- 
tive prosthesis.  The  operation  has 
been  abandoned  by  most  surgeons  in 
favor  of  the  Pirogoff  or  the  Syme 
method.  However,  it  is  still  per- 
formed, to  a  certain  extent,  in  Eng- 
land (Jacobson^°).  - 

The  technic  is  very  similar  to 
that  employed  in  Lisfranc's  ampu- 
tation, a  long  plantar  (Fig.  433) 
and  a  short  dorsal  flap  being  fash- 
ioned. The  foot  is  disarticulated  through  the  mediotarsal  joint  and 
the  flaps  sutured  and  drained  as  is  described  in  connection  with  the 
tarsometatarsal  disarticulation. 

The  siibastragaloid  amputation,  devised  to  overcome  the  objections 
to  Chopart's  method,  is  also  likely  to  be  followed  by  the  formation  of 
a  "pointed  stump,"  the  result  of  contracture  of  the  tendo  Achillis, 
though  this  is  regarded  as  somewhat  less  objectionable  than  obtains  in 
connection  with  the  mediotarsal  disarticulation.  Of  the  various 
methods,  that  of  Gunther"  is  the  most  serviceable ;  it  is  performed  as 
follows:  The  incision  (Fig.  436)  begins  at  the  tuberosity  of  the 
calcaneus,  in  the  middle  line  of  the  heel,  is  carried  in  a  gentle  curve 


Fig.   436. —  Incision   in   Gunther's 
subastragaloid     disarticulation. 


AMPUTATIONS 


891 


under  the  external  malleolus  and  turns  over  the  dorsum  of  the  foot 
on  a  line  with  the  mediotarsal  joint;    it  is  then  continued  around  the 


foot  across  its  sole  to  its  middle ;  from  here 
the  incision  is  carried  directly-  backward  and 
gradually  turns  upward  to  meet  the  point 
where  it  began  (Fig.  436).  The  knife  goes 
down  to  the  bone  throughout  the  entire  in- 
cision. The  joint  between  the  talus  and  the 
OS  navicularis  is  opened  first  and  the  con- 
nection between  the  former  and  the  calca- 
neus is  divided  next.  In  this  way  the  under 
surface  of  the  talus  is  freed;  the  foot  is 
rotated  sharply  outward  in  its  long  axis  and 
the  flap  thus  formed  is  dissected  free,  the 
knife  being  closely  apposed  to  the  calcaneus. 
Care  must  be  taken  not  to  invade  the  ankle 
joint. 

The  flap  is  united  with  interrupted  silk- 


FiG.  437. —  A,  Shows  the  Parts  Concerned  in  Subastragaloid  Disarticula- 

LATION.      B,    SuBASTRAGALOID    DiSiVRTICULATION    COMPLETED. 

Note  that  the  skin  from  the  sole  of  the  foot  covers  the  weight  bearing  end  of 
the  stump ;  also  note  the  position  of  the  drainage  tube. 

worm  gut  sutures  as  shown  in  Fig.  447,  which  also  shows  the  manner 
of  establishing  drainage.    The  leg  is  placed  on  a  posterior  splint,  the 


892     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

tube  is  removed  on  the  third  day  and  the  sutures  on  the  fourteenth, 
the  latter  being  left  in  situ  somewhat  longer  than  is  deemed  necessary 
when  there  is  less  tendency  toward  displacement  of  the  soft  parts. 

The  suhmalleolar  amputation  of  the  foot  (Syme)  is  performed  as 
follows:  The  operator  grasps  the  heel  with  the  left  hand,  fixing  the 
foot  at  right  angles  to  the  leg;  beginning  on  the  left  side  the  knife 
penetrates  the  soft  parts  at  the  tip  of  the  malleolus  and  carries  it  (in 
contact  with  the  bone)  across  the  sole  of  the  foot  to  the  opposite 
malleolus.  A  second  incision  across  the  anterior  aspect  of  the  ankle 
connects  the  ends  of  the  plantar  incision  and  also  divides  the  soft 
parts  down  to  the  bone  (see  incisions  for  Pirogoff 's  amputation,  Fig, 


Fig.  438. 


•  EXARTICULATION  THROUGH  THE  AnKLE  JOINI* 

(Syme). 


439).  The  anterior  incision  opens  the  talocrural  joint,  the  foot  is 
forcibly  extended  and  the  lateral  ligaments  divided.  Division  of 
these  ligaments  (the  talofibular  and  the  deltoid)  liberates  the  foot 
and,  when  the  latter  is  still  more  extended,  makes  the  posterior 
portion  of  the  capsule  accessible.  Section  of  the  capsule  exposes  the 
upper  surface  of  the  calcaneus  and  enucleation  of  this  bone  from  the 
heel  flap  becomes  comparatively  easy  (Fig.  438),  thus  completing 
exarticulation.  The  malleoli  are  sawed  off  level  with  the  surface  of 
the  tibia. 

The  heel  flap  is  sutured  to  the  skin  and  drainage  is  attained  (though 
not  as  effectively  as  is  desirable,  and  it  may  be  necessarj^  to  transfix 


AMPUTATIONS 


893 


the  dependent  portion  of  the  heel  flap)  in  quite  the  same  way  as  is 
shown  in  connection  with  the  subastragaloid  amputation   (Fig.  437). 


Fig.  439. —  Incisions  for  Disarticulations  Through  the 
Ankle  Joint  by  the  Syme  and  Pirogoff  Methods. 
The  plantar  portion   of  the   "stirrup"   incision   is   shown 
in  Fig.  433,  C. 

Disar  tic  ulation 
through  the  ankle 
joint  (Pirogoff)  is 
an  osteoplastic  sub- 
malieolar  amputa- 
tion. The  incisions 
are  similar  to  those 
employed  in 
Sijme's  method 
(Fig.  439)  and  the 
ankle  joint  is  also 
liberated  in  the 
same  way.  How- 
ever, after  the  pos- 
terior portion  of 
the  capsule  is  sec- 
tioned, the  technic 
is  different.  The  operator  now  grasps  the  foot  with  the  left  hand  and 
saws  the  calcaneus  in  the  manner  depicted  (Fig.  440),  the  bone  being 


Fig. 


440. —  Pirogoff 's     Amputation; 
Calcaneus. 


Sawing     the 


894    INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


sectioned  on  a  plane  with  the  anterior  transverse  incision.  The  soft 
parts  are  liberated  from  the  posterior  surface  of  the  malleoli  as  shown 
in  Fig.  441.  The  lower  ends  of  the  tibia  and  fibula  are  then  sectioned 
transversely  on  a  level  with  the  highest  point  of  the  articular  surface 
of  the  former.  At  this  time,  the  condition  of  affairs  is  as  depicted 
in  Fig.  442.  Various  methods  of  holding  the  sectioned  surface  of  the 
calcaneus  in  apposition  with  that  of  the  tibia  are  employed,  including 
bone  suture,  wiring, 
nailing,  etc.  Of  these, 
the  most  effective  one 
is  to  fashion  a  bone 
dowel  in  the  manner 
described  in  connec- 
tion with  arthrec- 
tomy  of  the  knee  (p. 
843),  drill  the  bones 
and  insert  the  dowel 
as  shown  in  Fig.  442. 
This  method  (in  the 
absence  of  infection) 
is  certain  to  be  fol- 
lowed by  prompt 
union  of  the  bony 
surfaces.  When  su- 
tured, the  flaps  ap- 
pear much  like  those 
shown  in  connection 
with  the  subastraga- 
loid  disarticulation 
(Fig.  437),  except 
that,  when  the  bones      „,        ,  .         .      ,     ,         .    .        ^.       ^ 

.  The  calcaneus  is  sectioned ;   the  posterior  sort  parts 

are  pegged  the  dram-  are   dissected  up   to  the  level  of  the  proposed  line  of 

age  tube  is  not  readily  division   of   the   lower   ends   of   the   bones   of  the  leg. 

..,.      1       ,  The  edge  of  the  knife  parallels  the  bones, 
utilized;    however,    a 

few  strands  of  silkworm  gut  may  be  used  instead.     The  care  of  the 

wound  and  the  after  treatment  are  similar  to  that  employed  after  the 

subastragaloid  operation  (p.  890). 

Amputations  through  the  Leg. —  Such  amputations  are  performed  by 

the  circular,  the  modified  circular,  the   hilaferal   equal   or  unequal 

cutaneous,  the  long  anterior  and  short  posterior  musculocutaneous 


Fig.    441. —  Pirogoff  's    Amputation. 


AMPUTATIONS 


895 


(Teale)  and  the  anterolateral  osteoplastic  flap  methods.  The  first 
four  are  described  in  connection  with  the  arm  and  forearm.  Of  these, 
the  modified  circidar  (in  which  a  periosteal  flap  may  be  used)  is  at- 
tended with  the  least  sacrifice  of  the  length  of  the  limb.  The  technic 
does  not  differ  from  that  described  in  connection  with  the  forearm 
(p.  874).  The  sharp  angle  of  the  tibia  should  always  be  removed. 
As  the  fibula  grows  until  the  twenty-seventh  year,  it  must  be  sectioned 
one  half  an  inch  higher  than  the  tibia  in  young  persons,  in  order  to 
prevent  its  protruding  beyond  the  latter. 


Fig.  442. —  Pirogoff's  Amputation. 
The  sawn  surfaces  of  the  bones  of  the  leg  {FT),  the  dependent  heel  flap  with 
sectioned   surface   of   the    calcaneus    (C)    are    shown.  ■     The   bone    dowel    {F)    i3 
inserted  into  the  calcaneus;   the  tibia  is  drilled   {E)  to  receive  it  when  the  heel 
flap  is  apposed  to  the  leg  stump. 

In  the  long  anterior  and  short  posterior  musculocutaneous  flap 
method  (Teale)  the  length  and  breadth  of  the  anterior  flap  is  made 
equal  to  one  half  the  circumference  of  the  leg  at  the  level  of  the  pro- 
posed bone  section.  The  posterior  is  made  fully  one  third  the  length 
of  the  anterior.  The  flaps  are  outlined  on  the  leg  as  shown  in  Fig. 
443.  The  knife  then  divides  the  soft  parts  on  the  anterior  surface  of 
the  \q^  down  to  the  bone  and  dissects  up  the  flap  which  contains  the 
anterior  tibial  artery  and  nerve  (the  periosteum  from  the  anterior 
^^pect  of  the  tibia  may  be  carried  up  with  this  flap)  ;   the  posterior 


896     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

flap  is  fashioned  in  a  similar  manner  (Fig.  444).  A  three  tailed 
retractor  is  introduced  (Fig.  408)  and  the  bones  are  sawed  (the  fibula 
is  sawed  first  and  is  sectioned  one  half  inch  higher  than  the  tibia),  the 
anterior  flap  is  folded  over  the  ends  of  the  bones  and  sutured  to  the 
posterior  flap,  and  the  portion  folded  below  the  bones  is  sutured  to 


Fig.  443. —  Teale's   Amputation;    Outline   op  Incisions. 

that  above  them  (Fig.  445)  ;  a  rubber  drainage  tube  is  introduced  in 
the  manner  shown  (Fig.  445).  The  limb  is  placed  on  a  posterior 
splint.  The  tube  is  withdrawn  on  the  third  and  the  sutures  on  the 
fourteenth  da}^     The  latter  should  not  be  removed  until  there  is 


Fig.  444. —  Flaps  Fashioned  in  Teale's  Amputation  through  the  Leg. 

reasonable  assurance  that  the  flap  is  healed  in  place.     The  stump  is  a 
very  satisfactory  one. 

In  the  anterolateral  osteoplastic  amputation  (Bier-Eiselsberg),  a 
flap  is  fashioned  from  the  anterior  inner  aspect  of  the  leg.  The  flap 
is  tongue  shaped ;  its  length  is  equal  to  one  half  the  circumference  of 


AMPUTATIONS 


897 


the  leg  at  the  level  of  the  bone  section  (Fig.  446).     The  tegumentaiy 
flap  is  dissected  up  and  the  periosteum  is  divided  slightly  higher  than 


Fig.  4-15. —  Teale's  Amputation  Completed. 
Note  position  of  drainage  tube. 

the  level  of  the  transverse  skin  incision  with  the  point  of  the  knife 
and  split  along  the  edges  of  the  anterolateral  aspect  of  the  tibia;    a 


Fig.  446. —  Osteoplastic  Amputation  through  the  Leg. 
O^eoplastie    Flap    resting    against    under    surface    of    cutaneus    flap     (Bier- 
liellslgffl-gLonnol'isq   ^^    ..ooy. 
gbfLstg  lotiJisqo  9f[T     :?:jro[ 


898     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


Fig.  447. —  Osteoplastic  Flap  Sutured 
OVER  the  Ends  op  the  Bones  (Bier- 
Eiselsberg). 


ness)  is  fashioned  and  fractured  at  its  base.  The  osteoperiosteal  flap 
is  elevated  as  shown  in  Fig.  446 ;  a  three  tailed  retractor  is  used 
to  protect  the  soft  parts  and 
the  bones  are  sawed  (the  fibula 
being  sectioned  first,  one  half 
inch  higher  than  the  tibia). 
The  osteoperiosteal  flap  is  su- 
tured over  the  ends  of  the 
bones  (Fig.  447)  and  the  tegu- 
mentary  flap  is  sutured^  as 
shown  in  Fig.  448.  The  illus- 
tration also  shows  the  method 
of  utilizing  rubber  tube  drain- 
age. The  after  treatment  is 
the  same  as  that  employed  after 
Teale's  amputation.  The  osteo- 
periosteal flap  constitutes  a 
considerable  addition  to  the 
weight  bearing  capacity  of  the 
stump.  The  method  is  particu- 
larly applicable  to  cases  of  injury  involving  the  outer  aspect  of  the  leg. 
Amputation  at  the  Knee.— Disarticulation  through  the  knee  joint 

may  be  accomplished  by  the 
circular,  modified  circular,  or 
as3'mmetrical  tegumentary 
flap  methods;  however,  the 
anatomical  conditions  in  this 
situation  render  these  less 
desirable  than  the  antero- 
posterior or  the  bilateral 
methods,  both  of  which  are 
described  here. 

The  long  anterior  tegu- 
mentary and  short  posterior 
musculocutaneous  disarticu- 
lation through  the  knee 
joint  is  performed  as  fol- 
lows :  The  operator  stands 
facing  the  flexed  knee  and  fashions  the  anterior  flap  by  entering 
the    knife    over    the    most    prominent    point    of    the    femoral    con- 


FlG 


448. —  Completed      Anterolateral 
Osteoplastic  Amputation  through  the 
Leg. 
Note  position  of  drainage  tube. 


AMPUTATIONS 


899 


dyle,  carries  it  straight  downward  to  the  level  of  the  upper 
end  of  the  tibia,  then,  in  a  shallow  curve  (concavity  upward),  the 
knife  divides  the  skin  and  subcutaneous  tissue  transversely,  crossing 
the  leg  three  to  four  finger  breadths  below  the  tubercle  of  the  tibia  and 
up  on  the  opposite  side  to  a  point  on  the  femoral  condyle  correspond- 
ing to  the  beginning  of  the  incision  (Fig.  449).  The  flap  thus  fash- 
ioned is  dissected  up  to  the  level  of  the  ligamentum  patellae.  At  this 
time,  the  short  posterior  flap  is  outlined  as  shown  in  Fig.  449.  The 
surgeon's  attention  is  again  directed  to  the  anterior  aspect  of  the 
joint;  with  a  goodly  sized  amputation  knife,  the  ligamentum  patellae 

is  divided,  the  leg  is  strongly 
^exed  and  the  lateral  and  crucial 
ligaments,  together  with  the  cap- 
sule, are  sectioned.  The  knife  is 
then  carried  around  the  upper 
posterior  edge  of  the  tibia  (close 
to  the  bone),  turned  sharply 
downward  and  the  soft  parts  cut 
in  the  line  of  the  previously  out- 
lined posterior  flap,  which  eon- 
tains  blood  vessels,  muscular  tis- 
sue and  the  popliteal  nerves.  The 
exarticulation  is  now  completed; 
the  nerves  are  pulled  down  and 
cut  oif  (one  inch  higher  up)  ;  the 
popliteal  artery  and  vein  are  tied ; 
minor  bleeding  is  arrested ;  a  one 
quarter  inch  rubber  drainage  tube 
is  introduced  and  allowed  to  pro- 
trude from  the  lateral  aspects  ol 
the  wound,  and  the  flaps  are 
united  with  interrupted  silkworm  gut  sutures.  The  limb  is  placed  on 
a  posterior  splint ;  the  tube  removed  on  the  third,  and  the  sutures  on 
the  tenth  day.  The  scar  is  located  at  the  posterior  aspect  of  the  stump, 
w^hich  is  an  excellent  one. 

The  dilateral  flap  method  of  disarticulation  at  the  knee  is  an  especial 
one  devised  for  amputation  in  this  region  in  connection  with  diahetic 
gangrene  of  the  foot  and  is  generall}^  credited  to  Stephen  Smith-\ 
As  a  desirable  method  of  disarticulation  at  the  knee  joint  it  has  ''stood 
the  test  of  time;"     however^  in  connection  with  the  diabetic  con- 


FiG.  449. —  Outlines  of  Incisions 
FOR  Disarticulation  through  the 
Knee  Joint  by  the  Long  Anterior 
Tegumentary  and  Posterior  Mus- 
culocutaneous Method. 


900     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


vVK: 


dition,  the  supracondyloid  amputation  (because  it  is  less  often  fol- 
lowed by  sloughing  of  the  flaps)  is  more  often  practiced. 

The  technic  is  as  follows:  The  incision  begins  about  one  inch  below 
the  tubercle,  and,  cutting  through  the  skin  and  muscular  tissues,  is 
carried  downward  and  forward  below  the  curve  of  the  leg,  thence 
inward  and  backward  to  the  middle  of  the  under  surface  of  the  leg, 
then  directly  upward  to  the  middle  of  the  popliteal  space.  The  oppo- 
site flap  is  fashioned  in  a  similar  manner,  the  inner  one,  because  of 
the  greater  length  and  size  of  the  internal  condyle,  being  cut  slightly 
longer.  The  flaps  are 
raised  to  the  apex  of  the 
patella ;  the  ligamentum 
patellae  is  cut  across,  the 
joint  opened,  the  crucial 
ligaments  sectioned,  the 
tibia  drawn  sharply  for- 
ward, and  a  long  amputa- 
tion knife  passed  behind  it. 
The  leg  is  now  slightly  ex- 
tended and  the  remaining 
tissues  cut  across.  Fig.  450 
shows  the  condition  of 
affairs  when  the  exarticu- 
lation  is  finished.  The 
semilunar  cartilages  are  re- 
moved in  all  instances.  A 
quarter  inch  fenestrated 
rubber  drainage  tube  is 
introduced  in  an  antero- 
posterior direction  and  the 
flaps  are  united  by  means 

of  interrupted  silkworm  gut  sutures.  The  limb  is  placed  on  a  posterior 
splint.  The  drainage  tube  and  sutures  are  removed  on  the  third  and 
fourteenth  day  respectively^  When  healing  is  completed,  the  scar  is 
located  at  the  posterior  aspect  of  the  thigh  and  the  end  of  the  stump 
is  well  adapted  to  weight  bearing. 

Amputations  through  the  Thigh. —  These  are  performed  through  the 
modified  circular  tegumentary,  the  equal  anteroposterior  musculo- 
cutaneous, and  the  long  anterior  and  short  posterior  musculocutaneous 


Fig.  450. —  The  Bilateral  Musculocuta- 
neous Flap  Method  of  Disarticulation 
THROUGH  THE  Knee  Joint  (Stephen 
Smith). 


AMPUTATIONS 


901 


methods.    In  amputating  in  the  region  of  the  condyles,  the  osteoplastic 
method  is  followed  by  stumps  of  great  weight  bearing  capacity. 

The  irregular  anteroposterior  flap  method  deserves  especial  mention ; 
it  is  performed  as  follows:  The  knife  enters  the  soft  parts  at  the 
middle  of  the  lateral  aspect  of  the  thigh  and  fashions  the  anterior  flap, 
consisting  of  skin  and  fascia  only,  in  the  manner  indicated  in  Fig.  451. 
The  posterior  flap  is  outlined,  as  is  also  shown  in  Fig.  451.  A  long 
amputating  knife  is  caused  to  transfix  the  soft  parts  close  to  the  bone 
(Fig.  451)  and  with  a  few  rapid  strokes  severs  the  musculature  in  the 
line  already'  outlined.  The  periosteum  is  divided ;  the  heel  of  the 
saw  is  placed  against  the  bone  and  the  femur  divided,  care  being  taken 
not  to  splinter  the  linea  aspera.  The  posterior  flap  may  be  cut  from 
without,  using  an  ordinary  scalpel  for  the  purpose.  In  addition  to 
the  femoral,  the  anastomotic,  and  the  descending  branch  of  the  ex- 


FiG.  451. —  Mixed  Long  Anterior  (skin  and  fascia)  and  Short  Posterior 
(musculocutaneous)  Flap  Amputation  through  the  Thigh  (Jacobson  aud 
Stewart). 


ternal  circumflex  must  be  tied.  As  the  femoral  artery  is  tied  in 
Hunter's  canal,  the  saphenous  nerve  must  not  be  included  in  the 
ligature.  The  saphenous  is  cut  as  high  as  possible,  as  is  also  the  sciatic 
nerve.  The  object  of  including  the  muscles  in  the  posterior  flap  is  to 
obviate  the  development  of  a  "pointed  stump"  and  to  conserve  its 
blood  supply.  The  anterior  flap  is  folded  over  the  end  of  the  stump 
and  fastened  to  the  short  posterior  flap  by  interrupted  silkworm  gut 
sutures  and  a  drainage  tube  is  introduced  across  the  stump.  The  limb 
is  placed  on  a  posterior  plint ;  this  is  especially  important,  as  it  con- 
trols the  "drag"  of  the  muscles  on  the  line  of  sutures,  which  causes 


902     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


much  pain.  The  tube  is  removed  on  the  third,  the  sutures  on  the 
twelfth,  day.  When  healed  the  sear  is  located  behind  and  above  the 
end  of  the  stump,  which  is  likely  to  be  a  very  serviceable  one. 


Fig.  452. —  Osteoplastic  Sttpracondyloid  Amputation  (Stokes). 

Amputations  in  the 
region  of  the  femoral 
condyles  have  been  some- 
what confused  in  the  lit- 
erature, despite  the  fact 
that  Jacobson^^  sub- 
mitted a  very  clear 
elucidation  in  this  con- 
nection in  1878.  Car- 
denas amputation  is  very 
like  that  of  Sj'me.  It 
consists  of  fashioning  a 
long  anterior  and  a  very 
short  posterior  tegu- 
mentary  tlap  and  saw- 
ing through  the  base  of 
the  eondj'les.  It  does 
not  differ  materially 
from     Teale's     method, 

nor  from  the  very  similar  method  described  in  connection  with  exar- 
ticulation  through  the  knee  joint.  Cardenas  is  not  an  osteoplastic 
amputation. 


Fig.  453. —  Osteoplastic  Stjpkacondtloid  Am- 
putation (Stokes). 
The  femur  is  sectioned;  the  posterior  surface  of 
the  patella  has  been  removed  and  the  posterior 
flap  fashioned.  The  popliteal  artery  and  vein 
and  the  internal  popliteal  nerve  are  shown. 


AMPUTATIONS  903 

Gritti's  and  Stokes'  amputations  are  both  osteoplastic  operations. 
The  difference  is  that  Gritti  saws  the  femur  through  the  shaft,  and 
Stokes,  above  the  condyles.  In  Gritti's  method  it  is  impossible  to  bring 
the  patella  down  over  the  end  of  the  sectioned  bone  without  tension  and 
at  times  this  cannot  be  done  at  all,  while  in  the  Stokes  method  it  is 
always  readily  accomplished.  Consequently,  it  would  seem  proper 
to  say  that,  when  the  transcondtloid  section  is  indicated,  Car- 
den's  METHOD  should  BE  EMPLOYED  AND,  WHEN  IT  IS  DESIRABLE  TO 
PERFORM  AN  OSTEOPLASTIC  AMPUTATION,   THE  SUPRACONDYLOID   METHOD 

OF  Stokes  be  selected. 

The  technic  of  the  Stokes'  amputation  is  as  follows:  The  incision 
is  begun  one  inch  above  and  slightly  behind  the  external  condj'le,  is 
carried  vertically  downward  to  a  point  opposite  to  the  tubercle  of  the 
tibia,  then  in  a  broad,  gentle  curve  (concavity  upward)  across  the  an- 
terior aspect  of  the  leg  to  a  point  opposite  to  that  from  which  it 
started.  The  flap  is  dissected  up  (the  ligamentum  patellae  being 
divided  en  route),  together  with  the  patella  (which  is  liberated  by  two 
lateral  incisions),  to  a  point  one  inch  above  the  condyles.  The  pos- 
terior surface  of  the  patella  is  removed  with  a  small  saw  (the  motor 
saw  may  be  used).  This  step  requires  a  little  patience;  the  patella 
being  a  sesamoid  bone  and  but  poorly  nourished,  must  not  be 
unduly  traumatized.  The  condition  of  affairs  at  this  stage  of  the 
operation  is  shown  in  Fig.  452.  The  knife  now  frees  the  femur  of 
its  soft  parts;  the  bone  is  sawed  across  and  a  short  musculocutaneous 
flap  is  fa.shioned  from  the  popliteal  space.  This  stage  of  the  procedure 
is  shown  in  Fig.  453.  The  popliteal  vessels  are  ligated  and  the  sciatic 
nerve  is  cut  as  high  up  as  is  possible.  The  patella  may  be  fastened 
to  the  end  of  the  femur  by  sutures  or  by  wire.  It  is  probable  that 
the  use  of  a  bone  dowel,  as  is  indicated  in  connection  with  Pirogoff  s 
amputation  (p.  893)  would  make  union  between  the  bones  certain.  In 
any  event,  a  drainage  tube  is  introduced  and  the  flaps  sutured.  The 
stump  is  placed  on  a  posterior  splint ;  the  drain  is  removed  on  the 
third,  and  the  sutures  on  the  twelfth,  day.  The  stump,  when  healed, 
possesses  satisfactory  weight  bearing  capacity. 

The  fashioning  of  a  motor  stump  in  connection  with  the  lower  ex- 
tremity is  still  of  undetermined  value  (see  Gaudiani^  and  his  bibli- 
ography). 

Amputation  at  the  Hip. — In  disarticulation  through  the  hip  joint 
temporary  control  of  bleeding  may  be  accomplished  in  a  manner 
similar  to  that  depicted  in  connection  with  exarticulation  through  the 


904     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


shoulder  joint.  Fig.  13  shows  the  method  of  introducing  Wyeth's^' 
pins  at  the  hip.  The  limb  is  first  exsanguinated  (by  means  of  the  v. 
Esmarch  elastic  bandage)  as  high  as  is  possible;  the  pins  are  intro- 
duced, the  constrictor  encircles  the  part  above  the  pins  (Fig.  13)  and 
the  bandage  is  removed. 

Exarticulation  at  the  hip  joint  by  the  combined  high  amputation 
and  subperiosteal  enucleation  of  the  head  of  the  femur  is  intended  to 
reduce  the  mortality  of  the  hip  amputation  to 
that  of  one  carried  through  the  thigh.  It  may  be 
performed  with  little  loss  of  blood ;  however,  the 
prolonged  manipulations  attendant  upon  the 
subperiosteal  removal  of  the  bone  would  seem 
quite  capable  of  promoting  shock;  nevertheless, 
unless  preservation  of  the  periosteum  is  readily 
accomplished,  this  step  of  the  procedure  may  be 
omitted. 

After  exsanguinating  the  limb  as  stated,  a 
circular  incision  through  the  skin  is  made  as 
indicated  in  Fig.  454.  When  the  skin  has  re- 
tracted, the  musculature  is  divided  down  to  the 
bone,  the  periosteum  is  sectioned,  and  the  bone  is 
sawed.  All  visible  blood  vessels  are  ligated  at 
this  time.  Next,  the  knife  enters  the  outer  aspect 
of  the  thigh  above  the  trochanter,  divides  the 
tissues  down  to  the  bone,  and  is  carried  down- 
ward to  connect  with  the  end  of  the  circular 
stump.  The  remaining  portion  of  the  femur  is 
now  seized,  and,  while  an  assistant  retracts  the 
soft  parts,  the  former  is  rapidly  enucleated  from 
the  musculature,  the  joint  is  opened,  the  caput 
femoris  is  luxated,  the  ligamentum  teres  is 
divided,  and  the  exarticulation  is  completed. 
The  gaping  wound  is  now  filled  with  gauze  com- 
presses wet  with  salt  solution,  and  the  pins  and 
the  constrictor  are  removed.  Cautiously  the 
moved  one  bj^  one,  and  as  a  bleeding  vessel  is  uncovered,  it  is 
ligated.  A  drainage  tube  and  silkworm  gut  sutures  are  intro- 
duced in  the  manner  shown  in  Fig.  455.  One  of  the  advantages 
claimed  for  the  subperiosteal  exarticulation  is  that  it  is  followed  by  a 
certain  degree  of  muscular  control  of  the  stump.     The  facts  in  this 


Fig.  454. —  Outlines 
OF  Incisions  in 
Disarticulation  at 
THE  Hip  Joint. 
Combination  of  cir- 
cular and  external 
perpendicular  in- 

cisions. 


compresses   are   re- 


AMPUTATIONS 


905 


connection  are  extensively  discussed  in  the  report  of  an  English  com- 
mission which  studied  a  case  of  Shuster's"^;  it  conveys  the  idea  that 
something  is  gained  in  this  direction  by  the  method  (see  Bibl.  No.  24). 
When  the  amputation  is  done  for  infection,  the  wound  is  not  sutured 
(Verneuil,-^  as  early  as  1877,  insisted  on  this),  hut  the  great  raw  sur- 
face is  loosely  tamponed  with  sterile  gauze,  and  a  secondary  repair  by 
suture  is  made  when  healthy  granulations  make  their  appearance.  If 
the  healing  is  delaj'ed  by  the  presence  of  sloughing  tissue,  the  gauze 
tampon  may  be  kept  wet  with  Dakin's  solution  (p.  246).  In  this  class 
of  cases  the  agent  seems  to  exercise  a  peculiar  solvent  action  upon  the 
devitalized  tissue. 

As  stated  above,  a  typical  method  of  amputating  does  not  always 


Fig.  455. —  Completed  Disarticulation  at  the  Hip  Joint. 
The  wound  is  sutured.      Note  position  of  the  drainage  tube. 


best  meet  the  indications.  This  is  especially  true  in  connection 
with  exarticulation  at  the  hip  joint.  For  this  reason,  a  so-called 
extirpation  method  which  is  particularly  applicable  in  cases  of  neo- 
plasm in  this  situation  is  described. 

Atypical  extirpation  at  the  hip  joint  may  be  performed  by  a  method 
which  corresponds  to  the  oval  incision  described  in  connection  with 
Spence's  amputation  at  the  shoulder  (p.  883).  The  technic  is  as  fol- 
lows: A  vertical  incision  begins  over  the  middle  of  Poupart's  liga- 
ment and  is  carried  straight  down,  to  the  junction  of  the  upper  and 
middle  thirds  of  the  thigh.    Through  this  the  femoral  arterj^  is  ligated 


906     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

just  below  Poupart's  ligament  (p.  1014),  and  its  branches  are  tied  as 
they  appear.  At  the  lower  end  of  the  vertical  incision  a  circular  one 
is  made  corresponding  to  that  described  immediately  above  and  shown 
in  Fig.  454.  The  skin  is  allowed  to  retract,  the  muscles  are  divided 
with  the  scalpel,  layer  by  layer,  bleeding  being  arrested  en  route. 
Gradually  all  the  soft  parts  are  sectioned  down  to  the  bone  wath  but 
little  loss  of  blood.  Finally,  the  bone  is  separated  from  its  ligamentous 
attachments  (under  the  eye)  and  the  exarticulation  is  completed.  The 
wound  is  drained  and  sutured  precisely  as  is  described  in  connection 
with  the  Spence  operation  (p.  883).  In  most  publications  devoted 
exclusively  to  operative  technic,  various  additional  methods  of  disar- 
ticulation at  the  hip  joint  are  described.  None  of  these  involve 
measures  not  taken  up  in  the  description  of  operations  presented  in 
connection  with  the  amputation  of  special  parts.  Here  again,  at  the 
close  of  this  chapter,  it  is  suggested  that  the  reader  view  the  problem 
from  the  standpoint  of  the  general  principles,  which,  it  is  hoped, 
have  been  brought  out  in  the  text.  The  character,  site,  and  extent  of 
lesions  demanding  amputations  are,  of  course,  varied,  and  also,  of 
course,  demand  varied  operative  measures  of  relief.  It  is  perhaps  not 
going  too  far  to  say,  that  the  sacrifice  of  a  sector  of  a  part  in  order  to 
conform  to  a  classic  method  of  amputation  is  not  good  surgery  and 
that,  to  a  certain  extent,  the  surgeon's  ability  to  devise  a  method  of 
procedure  suitable  to  a  given  problem  is  indicative  of  his  technical 
qualifications. 


BIBLIOGRAPHY 

1.  Bryant.     Op.  Surg,  i,  Appleton,  N.  Y.  and  London,  1905. 

2.  DuBREUiL.     Precis  d'Oper.  de  Chir.  par  le  Dr.  J.  Chauvel. 

3.  Gaudiani.     Anns.  Surg,  xvii,  No.  4,  1918. 

4.  Vanghetti.     Arch.  Ital.  di  Orthop.  Anno,  xvi,  1899. 

5.  VON  "Wreden.     Zentrbl.  f.  Chir.  and  mech.  Orthop.  Bd.  ii,  1908. 

6.  De  Francesco.     Revista  Osped.  vii,  xiii,  xiv. 

7.  Pieri.     Same  as  No.  6. 

8.  SAUERBRrcH.     Die  willkiirlich  bewegbar  Hand.  Springer,  Berlin,  1916. 

9.  PuTTi.     See  Gaudiani  No.  3. 

10.  Jacobson  and  Steward.     Op.  of  Surg,  i,  Phila.,  1902. 

11.  Spence.     Lectures  on  Sui*gery,  ii. 

12.  Berger.     L'amp.  du  IMemb.  sup.  dans  la  contig.  du  Tronc,  Paris,  1887. 

13.  Kocher.     Operations  Lehre,  Jena,  1902. 

14.  Le  Conte.     Anns.  Surg.,  September,  1899. 

15.  V.  Langenbeck.     Arch.  f.  khn.  Chir.  Bd.  iii,  18G2. 

16.  OLLnsR.    Lyon  Med.,  1885,  xviii. 


A:\IPUTATI0XS  907 

17.  Keen.    Anns.  Surg.,  June,  1895. 

18.  Fowler.     Anns.  Surg.,  January  and  February,  1900. 

19.  GuNTHER.     See  Zuckerkandl's  Operations  Lehre,  Miinieh,  1905. 

20.  BiER-EiSELSBERG.     Same  as  Xo.  19. 

21.  Smith.     N.  Y.  Jr.  Med.,  September,  1852,  and  Amer.  Jr.  Med.   Sci., 

January,  1870. 

22.  Jacobson.     Guy's  Hosp.  Report,  xxiii,  1878. 

23.  Wyeth.     Anns.  Surg.,  1897,  i,  and  Jr.  A.  M.  A.,  May  18,  1901. 

24.  Shuster.     Report  of  English  Commission,  Trans.  Clinic  Soc,  London, 

xvi. 

25.  Verneuil.    Paris  Acad,  de  Med.,  1877. 


CHAPTER  YIII 

GUNSHOT  WOUNDS 

As  the  outcome  of  the  peculiar  coiiditious  caused  by  the  "World 
War,"  volumes  have  been  written  about  "war  surgery."  The  stu- 
dent is  advised  that  the  problem  of  ' '  war  wounds ' '  presents  but  few 
factors  not  taken  up  in  the  general  consideration  of  wounds  (p.- 27) 
classified  as  contused,  lacerated,  etc.,  and  their  care  does  not  differ  from 
that  described  in  this  connection.  The  special  factors  entering  into 
wounds  produced  by  projectiles  are  taken  up  in  this  chapter. 

Gunshot  wounds  are  produced  by  arms  of  small  caliher  or  by 
artillery. 

In  civil  life  the  so-called  small  arm  wound  is  produced  by  small 
shot  (bird  shot,  etc.)  or  by  the  ordinary  lead  (soft  or  hard)  bullet. 
The  great  expansive  power  of  smokeless  powder  and  the  demands  it 
makes  upon  the  life  of  the  rifle  has  made  it  necessary  to  coat  the 
projectiles  with  steel  jackets,  which  either  completely  encase  the  cen- 
tral portion  of  soft  or  hard  lead  or  leave  the  tip  uncovered.  The 
modern  military  rifle  is  of  small  caliber  (6-8  mm.)  in  contrast  to 
the  older  Chassepot  and  Mauser  (11  mm.)  and  the  center  needle  fire 
rifle  of  13.6  mm. 

Wounds  Produced  by  Rifle  Bullets. — Wounds  produced  by  rifle  pro- 
jectiles {en  masse  or  splintered)  present  a  2^ort  of  entrance,  a  ivound 
canal,  and,  when  the  projectile  traverses  the  body,  a  port  of  exit. 
The  last  is  usually  larger  than  the  port  of  entrance,  though  both  take 
on  the  character  of  a  contused  and  lacerated  wound.  The  u'ouncl  canal 
is  usually  straight.  When  the  velocity  of  the  projectile  is  slight,  it 
may  be  deflected  from  its  course  b}^  coming  in  contact  with  bone  and 
form  the  arc  of  a  circle  {contour  gunsJwt  tvounds).  In  these  in- 
stances, the  diameter  of  the  wound  canal  conforms  to  that  of  the  pro- 
jectile, but  it  may  gradually  enlarge  toward  the  port  of  exit,  taking 
on  a  funnel  shape.  Under  certain  conditions  the  tissues  contiguous  to 
the  wound  canal  are  extensively  rent  asunder  b}^  the  hur sting  action 
of  the  projectile,  which  splinters  the  bone  and  is  itself  subdivided  so 
that  several  ports  of  egress  may  be  established. 

908 


GUNSHOT  WOUNDS 


909 


Fig.  456. —  Destruction  of  the  Elbow  Joint  Caused  by  a  Lead  Pointed  (Dum- 
Dum)  Bullet  Fired  at  Close  Kange. 


Fig.  457. —  Kontgenogeaji  of  Injury  Shown  in  Fig.  456. 


910     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  character  and  extent  of  a  gunshot  wound  are  dependent  upon  a 
number  of  factors,  chief  of  which  are  deformation  of  the  projectile 

AND  ITS  power  OF  PENETRATION. 

The  greater  resistance  the  tissues  present  to  the  penetrating  power 
of  the  projectile,  the  more  is  the  latter  deformed  and  the  more  ex- 
tensive is  the  injury.  The  soft  lead  and  the  partially  jacketed 
PROJECTILES  undergo  THE  GREATEST  DEFORMATION.  The  latter  pro- 
duce the  most  extensive  wounds,  especially  when  fired  at  close  range 
(600  yards),  as  they  possess  tremendous  initial  velocity  and  great 
potential  energy.  The  impact  spreads  the  central  portion  (of  hard- 
ened lead)  causing  the  projectile  to  take  on  a  "mushroom"  form  or  to 
be  subdivided  into  splinters  which  penetrate  the  tissues  in  various 
directions.  In  this  way  the  tissues  are  torn  and  lacerated  over  wide 
areas,  a  condition  of  affairs  greatly  increased  when  the  bone  is  in- 
jured. The  use  of  this  form  of  projectile — the  partially  jacketed,  the 
soft  nosed,  or  Dum-Dum  (named  for  the  munitions  factory  near  Cal- 
cutta), and  the  hollow  nosed,  has  been  prohibited  by  the  International 
Congress  at  the  Hague.  A  fully  jacketed  projectile  may  undergo  de- 
formation by  contact  with  a  hard  substance  before  entering  the  body. 

The  power  of  penetration  of  a  projectile  depends  upon  its  initial 
velocity,  its  potential  energy,  and  its  hardness,  form,  and  caliber. 
The  modern,  full  jacketed  rifle  projectile  has  great  power  of  pene- 
tration, and  for  this  reason  ordinarily  it  is  not  as  likely  to  become 
embedded  in  the  tissues  as  the  soft  lead  variety.  When  it  is  not 
deformed,  and  when  it  is  not  caused  to  swerve  from  a  direct  course, 
as  a  rule,  it  produces  a  small  port  of  entrance,  a  long,  narrow,  wound 
canal,  and  an  exit  port  of  moderate  size. 

However,  when  this  projectile  comes  in  contact  with  hone  or  with 
organs  which  contain  fluid  and  are  covered  with  a  resisting  capsule, 
sUch  as  the  skull,  the  heart,  a  full  stomach  and  gut,  the  liver,  the 
spleen  and  the  kidneys,  the  destruction  of  tissue  is  likely  to  be  appal- 
lingly extensive.  This  hursting  action  is  explained  on  the  basis  of 
hydrodynamics,  and  occurs  in  connection  with  lead  projectiles  at  a 
distance  of  400  yards,  and  at  a  greater  distance  with  the  jacketed 
form.  In  the  latter  instance  the  bone  is  shattered  after  the  projectile 
has  traveled  1,600  yards.  Extensive  laceration  of  soft  parts  is  mani- 
fest only  when  the  projectile  is  fired  at  close  range.  The  bursting 
effect  is  produced  by  the  motion  of  the  projectile  and  occurs  in  the 
direction  it  travels.  The  force  of  impact  increases  the  pressure  in  the 
tissues  in  a  certain  restricted  area  and  is  then  diffused  radially  in  all 


GUNSHOT  WOUNDS  911 

directions,  though  this  radial  distribution  is  greatest  in  the  direction 
oi  least  resistance.  When  this  force  is  expended,  backward  pressure 
toward  the  wound  of  entrance  occurs,  but  when  the  projectile  tra- 
verses the  part,  the  greatest  pressure  acts  upon  the  area  of  the  wound 
of  exit.  After  the  projectile  has  passed  through  the  body  the  tissues 
contiguous  to  both  the  wounds  of  exit  are  again  forced  into  the  wound 
canal  by  the  sudden  forcible  entrance  of  air. 

The  mechanism  of  the  hursting  action  of  the  modern  high  velocity 
projectile  may  be  accurately  recorded  in  pictures  by  the  single  and 
multiple  spark  photographic  method,  which  makes  it  possible  to  utilize 
a  period  of  illumination  of  a  millionth  part  of  a  second. 

Wounds  produced  by  small  shot  fired  at  close  range  are  attended 
with  extensive  laceration  of  tissue  which,  however,  is  limited  to  the 
port  of  entrance. 

The  manifestations  consequent  to  gunshot  wounds  are  determined 
by  the  location  of  the  injury.  An  immediately  fatal  issue  occurs  most 
frequently  in  connection  with  injuries  of  the  vital  organs — the  heart, 
the  brain,  and  the  large  blood  vessels. 

Symptoms. — The  primary  symptom  of  a  gunshot  wound  is  a  short, 
dull  pain  which,  when  the  missile  is  of  small  caliber,  is  very  likely  to 
be  slight,  and  even  in  cases  of  wounds  of  the  thorax  and  abdomen  may 
be  compared  to  the  pain  associated  with  the  impact  of  a  small  stone. 
Injuries  of  bones,  joints,  and  nerves  are  attended  with  severe  pain. 
Gunshot  wounds  of  the  brain  are  attended  with  uncanscionsness; 
those  of  the  spinal  cord  with  paralysis.  Local  shock  in  the  vicinity 
of  the  wound  soon  abolishes  sensation,  and,  when  the  injury  is  ex- 
tensive, an  entire  section  of  the  body  may  become  cool,  pale,  and  in- 
sensible. General  shock  is  proportionate  to  the  extent  and  location 
of  the  injury. 

Hemorrhage  varies  widely  in  degree.  As  a  rule,  the  external  flow 
of  blood  is  proportionate  to  the  size  of  the  skin  wound  and  the  dia- 
meter of  the  wound  canal.  Even  when  large  blood  vessels  are  in- 
jured, the  external  discharge  of  blood  may  be  slight,  it  being  inter- 
fered wath  by  the  early  formation  of  thrombi  and  deformation  of  the 
wound  canal.  On  the  other  hand,  extensive  hematomata  are  likely 
to  develop  in  the  soft  parts  and  in  the  cavities  of  the  body,  which  may 
lead  to  death  from  internal  bleeding.  The  older  lead  projectile  pushed 
the  elastic  blood  vessels  aside,  but  the  jacketed  form  of  modern  times 
often  divides  them  and  is  more  frequently  responsible  for  bleeding, 
but  this  is  less  likely  to  be  fatal. 


912     INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 

Wounds  of  the  Skin. — Gunshot  wounds  of  the  skin  present  a  variety 
of  characteristics.  Projectiles  of  low  velocity  may  cause  a  simple 
superficial  contusion  {rebound  gunsJiot  wound).  AYhen  the  projectile 
strikes  the  body  squarely,  the  ^Yound  of  entrance  is  round,  sharply 
defined,  and  corresponds  closely  to  the  projectile  in  size.  Wounds 
produced  by  jacketed  projectiles  may  be  smaller  than  the  missile,  as 
the  skin  is  stretched  by  the  point  before  penetration  occurs.  Usually 
the  edges  of  the  u'ound  are  contused  and  somewhat  funnel  shaped, 
except  where  subcutaneous  bone  is  injured,  when  they  may  be  everted, 
and  larger  than  when  soft  parts  alone  are  injured.  When  gunshot 
wounds  are  produceel  at  very  close  range  (accidental  or  suicidal), 
their  borders  are  burned  and  the  surrounding  skin  is  filled  with 
powder  grains.  The  latter  are  difficult  to  remove.  Those  more  super- 
ficially located  may  be  expelled  by  artificially  produced  inflammation 
such  as  follows  the  application  of  a  one  per  cent  solution  of  corrosive 
sublimate.  In  suicidal  wounds,  in  the  production  of  which  the  muzzle 
of  the  firearm  is  held  close  to  the  skin,  or  is  enclosed  hij  the  tips,  a 
bursting  wound  is  produced  as  the  result  of  the  explosion  of  the  gases. 
In  simple  perforating  wounds  of  soft  parts  the  port  of  exit  is  about  the 
same  as  that  of  entrance;  when,  however,  the  explosive  action  of  the 
projectile  is  brought  into  pla}',  the  former  is  larger  and  presents  ir- 
regular, flap  shaped,  everted,  or  "cupped,"  edges  and  may  contain 
splinters  of  bone  when  this  is  injured.  Large  gaping  u'ounds  of  exit 
are  produced  by  lead  projectiles  and  by  partialh*  jacketed  ones  at  a 
distance  of  200  yards. 

Deflected  projectiles  which  strike  the  body  transversely  or  ohliquely 
produce  oval  or  slit  formed  wounds  of  entrance  and  egress;  when 
deformed  the  resultant  wounds  are  irregular  in  outline.  Multiple 
wounds  of  entrance  and  egress  occur  in  connection  with  injuries  pro- 
duced by  small  caliber  projectiles  which  traA'erse  several  portions  of 
the  body  successively,  perforating  folds  of  the  skin  or  prominent 
muscular  protrusions. 

Projectiles  striking  the  bod}'  tangcntially  produce  long,  grooved 
wounds.  When  the  skin  is  perforated  and  the  projectile  proceeds 
beneath  the  skin  its  course  is  indicated  by  a  streak  of  ecclnTnosis. 

The  diameter  of  the  wound  canal  conforms  in  a  general  way  to  the 
caliber  of  the  projectile,  provided  the  latter  is  not  deformed.  When 
the  explosive  action  of  a  projectile  fired  at  close  range  comes  into  play, 
the  wound  canal  is  represented  by  a  mass  of  disintegrated  tissue  lead- 
ing to  an  extensive  wound  of  exit, 


GUNSHOT  WOUNDS  913 

Wounds  of  Blood  Vessels. — Blood  vessels  injured  by  projectiles  may 
be  contused  and  subsequently  may  undergo  necrosis  and  may  be 
partially  or  completely  divided.  Wounds  of  small  arteries  do  not 
differ  from  those  inflicted  in  other  ways;  they  cicatrize  (even  when 
the  aorta  is  injured)  or  lead  to  the  formation  of  traumatic  aneurism. 
When  a  projectile  injures  an  artery  and  a  vein  in  its  passage  between 
them,  an  arteriovenous  aneurism  (p.  981)  is  formed. 

Wounds  of  Peripheral  Nerves. — Peripheral  nerves  are  more  likely  to 
be  completely  severed  by  lead  projectiles  than  by  the  full  jacketed 
kind.  The  latter  may  simply  produce  a  slit  formed  perforation  of  a 
nerve  trunk,  even  though  the  thickness  of  the  nerve  is  no  greater 
than  the  caliber  of  the  projectile.  The  manifestations  of  gunshot 
injuries  of  nerves  are  those  of  paralysis.  When  the  nerve  is  not 
completely  divided  the  sjTnptoms  are  likely  to  disappear  in  a  few 
weeks.  Neuralgia  and  neuritis  follow  the  pressure  of  a  projectile 
located  or  lying  in  contact  with  a  nerve  trunk. 

Wounds  of  Bones. — Gunshot  wounds  of  bones  consist  of  contusions 
(when  produced  by  spent  bullets),  perforations  and  fractures  ivith 
comminution  and  fissures. 

Soft  lead  projectiles,  which,  are  easily  deformed,  fired  at  long 
range,  are  likely  to  produce  simple  contusion  of  the  bone,  attended 
with  periosteal  and  medullarv'  ecchymosis.  In  some  instances  the 
impact  of  a  projectile  of  this  kind  produces  a  relatively  slight  con- 
tusion of  the  skin,  but  fractures  the  underlying  bone. 

Symmetrical  perforation  of  the  spongiosa  is  produced  by  jacketed 
projectiles,  unless  they  are  fired  at  close  range  or  are  deformed.  When 
the  projectile  traverses  the  bone  at  right  angles,  the  wound  canal 
gradually  widens  and  the  port  of  exit  is  larger  than  the  port  of  en- 
trance ;  when  it  strikes  tra^jentially,  the  projectile  cuts  a  groove  in  the 
surface  of  the  bone.  Soft  lead  projectiles  rarely  produce  simple  per- 
forations, but  usually  cause  comminution  and  fissures,  and  they  fre- 
quently remain  imbedded  in  the  sJDongiosa,  where  they  cause  much 
destruction.  Gunshot  wounds  of  the  flat  bones  exhibit  similar  char- 
acteristics except  in  the  cranium,  where  bursting  fractures  extending 
into  the  base  are  common. 

In  the  diaphyses  (where  the  bone  is  brittle),  projectiles  of  both 
classes  produce  much  comminution.  Projectiles  fired  at  close  range 
shatter  the  bone  into  smaller  splinters  than  when  fired  from  a  long 
distance  (Fig.  4.58),  but  in  both  instances  the  zone  of  comminution 
is  the  same.    In  the  typical  diaphyseal  gunshot  fracture  the  comminu- 


914     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

tion  is  likely  to  take  on  the  so-called  ''butterfly  fracture"  form,  wliicli 
is  characterized  by  two  fissures  extending  in  either  direction  from  the 
point  of  impact,  thus  forming  two  lateral  fragments  (the  wings  of  a 
butterfl}')-    When  the  bone  is  not  traversed  at  the  site  of  its  greatest 

a 


Fig.  458. — Fractures  of  the  Diaphysis  of  the  Humerus  Caused  by  a  Jacketed 

Bullet.      (After  Kiittner.) 

a,  Close  range  (up  to  180  yards)  ;  &,  long  range  (1,000-2,000  yards). 


diameter,  the  four  fissures  are  irregular  and  are  supplemented  by  addi- 
tional smaller  ones  (Fig.  459).  Fissures  often  extend  into  contiguous 
joints.  OhJique  and  transverse  fractures  are  caused  by  projectiles 
which  graze  the  bone. 


GUNSHOT  WOUNDS 


915 


The  degree  of  destruction  of  tissue  continguous  to  the  injured  bone 
is  in  proportion  to  the  distance  traversed  by  the  projectile  before  im- 
pact occurs.     The  area  of  injury  is  filled  with  blood,  particles-  of  soft 


a  5 

Fig.  459. —  Gunshot  Wound  of  the  Lower  End  of  the  Eight  Humerits. 
a.  Wound  of  entrance  on  posterior  surface;  h,  ■wound  of  exit  anterior. 

parts,  and  splinters  of  bone,  and  is  most  extensive  beyond  the  point 
where  the  projectile  emerges  from  the  bone.  "When  the  bone  lies  im- 
mediately beneath  the  skin  the  wound  of  exit  is  likely  to  be  very 


Fig.  460. —  Comminuted  Fracture  of  the  Tibia. 


large.  If  the  bone  is  thickly  covered  by  soft  parts,  the  wound  of  exit 
is  not  markedly  larger  than  that  of  entrance.  Projectiles  fired  at 
2,000  yards  or  more  do  not  cause  much  destruction  of  tissue,  a&  the 


916     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

bone  fragments  are  not  widely  separated  and  may  maintain  connec- 
tion with  the  periosteum. 

Wounds  of  Joints. — Gunshot  wounds  of  joints  are  almost  always 
attended  with  fractures,  and  when  the  provocative  missile  is  of  lead, 
comminution  also  occurs  (Fig.  461).  Projectiles  fired  from  revolvers, 
pistols,  etc.,  possess  little  velocity,  do  not  cause  much  destruction  of 
bone,  and  are  likely  to  become  embedded  in  the  capsule  or  the  liga- 
ment of  a  joint. 

Wounds  of  Organs  and  Cavities. — Of  the  injuries  of  the  cavities  and 
their  organs,  those  of  the  skull  are  attended  with  the  highest  mortality. 
Projectiles  fired  at  close  range  cause  extensive  hursting  fractures,  es- 
pecially those  produced  b.y  the  high  velocity  small  caliber  bullets,  and 
are  usually  fatal.     As  a  rule,  the  brain  is  macerated,  presenting  a 


Fig.  461. —  Gunshot  Wound  of  Head  of  the  Humerus. 
Splintered   fracture   of   the   head   of   the   humerus.      Long  head   of  the  biceps 
divided  by  a  fragment  of  bone.      Bullet  imbedded  in  the  bone. 

bloody,  disintegrated  pulp  interspersed  with  man}^  fragments  of  bone. 
Projectiles  fired  at  middle  or  long  range  produce  moderate  comminu- 
tion of  bone  or  simple  perforations  with  radiating  splinters.  In  these 
wounds  the  brain  itself  is  not  extensively^  torn,  so  that  when  an  un- 
important portion  of  the  brain  is  injured  and  hemorrhage  or  menin- 
gitis does  not  ensue,  recovery  may  occur  with  encapsulation  of  the 
projectile. 

In  the  ahdominal  cavity,  gunshot  wounds  present  a  menacing  con- 
dition of  affairs.  As  important  blood  vessels  and  organs,  especially 
the  gastro-intestinal  canal,  are  often  injured  (the  latter  in  several 
places),  a  fatal  outcome  from  hemorrhage  or  peritonitis  is  likeh'  to 
occur.  At  times,  perforation  of  the  gastro-intestinal  canal  by  a  small 
caliber  projectile  heals  spontaneously  as  the  result  of  the  rapid  forma- 


GUNSHOT  WOUNDS  917 

tion  of  adhesions,  though  this  outcome  may  be  regarded  as  rare  and 
probably  never  occurs  when  the  injury  is  produced  by  a  lead  bullet. 

Gunshot  wounds  of  the  thorax  are  immediately  fatal  when  the 
heart  or  large  blood  vessels  are  injured.  Excluding  these,  recovery  is 
not  uncommon,  though  secondary  putrefactive  infection  and  hemo- 
thorax claim  a  number  of  victims.  "Wounds  of  the  lung  are  not  sub- 
ject to  the  bursting  action  of  the  projectile  and  have  a  tendency  to 
heal  spontaneously.  As  a  rule,  the  wound  canal  is  not  irregular  in 
direction.  A  fatal  outcome  from  hemorrhage  supervenes  when  one  of 
the  large  branches  of  the  pulmonary  artery  is  severed  or  when  the 
lung  is  torn  by  a  fragment  of  a  fractured  rib. 

Wounds  Caused  by  Artillery  Projectiles. — Injuries  produced  by 
ariUUry  projectiles  or  by  hcniel  greneieles  are  still  more  extensive  than 
those  caused  by  arms  of  small  caliber  fired  at  close  range. 

The  various  heavy  arms — cannons,  howitzers,  and  mortars — dis- 
charge exploding  grenades  and  shrapnel.  The  exploding  shells  are 
filled  with  hollow  projectiles,  which  are  liberated  by  the  bursting  of  the 
shell,  and  are  propelled  in  every  direction.  The  velocity'  of  the  liberated 
projectile  varies  from  450  to  1,000  yards  per  second.  The  ordinary 
shrapnel  case  contains  from  300  to  500  hard  lead  bullets  weighing  10 
grams  each  which,  when  released  by  the  bursting  of  the  case,  have 
greater  destructive  action  than  fragments  of  the  shell  itself.  Shrapnel 
cases  are  exploded  by  a  time  fuse  which  ignites  the  explosive  they 
contain,  .an  arrangement  which  permits  the  explosion  to  be  timed  so 
that  it  occurs  while  the  projectile  is  in  flight,  i.  e.,  above  or  in  front 
of  the  target. 

SheJl  splinters,  shrapnel  bullets,  and  so-called  indirect  projectiles 
(particles  of  stone  and  wood)  produce  severe  laceration  and  contusion 
of  tissue,  both  at  the  port  of  entrance  and  of  exit,  though  the  greatest 
trauma  occurs  at  the  latter.  The  wound  of  entrance  is  often  the  site 
of  particles  of  clothing  and  shreds  of  tissue,  while  disintegrated 
muscle,  torn  tendons,  and  splinters  of  hone  protrude  from  the  wound 
of  exit.  The  extent  of  the  injury  varies  with  the  size  and  velocity  of 
the  projectile ;  a  spent  shrapnel  ball  may  simply  contuse  the  soft  parts, 
while  a  direct  impact  may  avulse  an  entire  limb. 

The  shock  of  a  shell  exploding  in  the  vicinity  of  the  hody  may  pro- 
duce fatal  internal  injuries,  sensory  paralysis,  and  cerebral  concus- 
sion ;  or,  the  motion  of  the  air  may  force  the  body  against  a  tree  or 
wall,  causing  the  production  of  open  wounds. 

Wounds  caused  by  artillerj'-  projectiles  are  dangerous  not  alone 


918     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

because  of  their  extent,  but  also  because  they  are  likel}'  to  become  in- 
fected as  the  result  of  the  degree  of  trauma  to  which  the  tissues  are 
subjected. 

The  clinical  course  of  gunshot  wounds  depends  (aside  from  the 
factor  of  hemorrhage)  upon  their  location,  the  degree  of  inj^iry,  and 
whether  infection  occurs. 

Primary  infection  in  gunshot  wounds,  as  in  all  accidentally  in- 
flicted injuries,  is  not  a  grave  menace,  though  its  possibility  must  al- 
ways be  taken  into  account.  Experimentall}^  it  has  been  shoM^n  that 
projectiles  carry  infection  into  the  wound  (especiall}"  from  the  cloth- 
ing and  the  skin),  and  also  that  highly  virulent  bacteria  attached  to 
projectiles  may  be  carried  into  the  bodies  of  susceptible  animals  and 
give  rise  to  fatal  infection ;  however,  the  fact  remains  that  primary 

INFECTION  IS  USUALLY  OVERCOME   BY   THE  LOCAL.  ANTIBODIES  AND   THAT 

HEALING  WITHOUT  INFLAMMATION  IS  THE  RULE.  This  explains  the  fact 
that  even  pieces  of  clothing  carried  into  a  joint  ma}^  become  encapsu- 
lated without  producing  appreciable  disturbances.     From  a  clinical 

STANDPOINT,  MOST  GUNSHOT  WOUNDS  MAY  BE  REGARDED  AS  CLEAN,  IF 
THEY    CAN    BE    PROTECTED    FROM    SECONDARY    INFECTION.       Small    shot 

wounds  and  those  produced  by  blank  cartridges,  in  which  the  "wad" 
enters  the  tissue,  are  the  exception  to  this  rule.  The  former  are  often 
followed  by  putrefactive  phlegmon,  the  latter  by  tetanus.  The  "wad" 
used  in  ammunition  of  this  sort  is  made  of  rag  paper,  and  the  presence 
of  tetanus  bacilli  is  shown  in  57.14  per  cent  of  those  subjected  to  bac- 
teriological examination. 

On  the  other  hand,  secondary  infection  is  a  grave  menace  in  con- 
nection with  gunshot  w'ounds.  Extensive  laceration  of  the  tissues 
presents  the  greatest  danger  of  infection.  The  danger  in  this  regard 
diminishes  in  proportion  to  the  size  of  the  wound  and  the  promptness 
with  which  the  protective  dressing  is  applied.  Infection  occurs  most 
frequentl}^  in  w^ounds  which  are  subjected  to  search  of  the  projectile 
by  means  of  probes,  the  finger,  etc.,  or  are  lavaged  or  injected  with 
various  so-called  bactericidal  solutions.  Measures  of  this  sort  carry 
infective  excitants  from  the  outer  layers  of  the  blood  clot  and  skin 
into  the  deeper  tissues  and  mechanically  lessen  the  resistance  of  the 
latter  to  infection.  The  al)sence  of  infection  in  wounds  of  the  knee 
joint  which  are  simply  covered  wuth  sterile  gauze  is  explained  on  this 
basis. 

Recognition  of  the  character  of  a  gunshot  wound  is  based  on  the 
clinical  picture  presented  by  disturbances  consequent  to  the  injury, 


GUNSHOT  WOUNDS  919 

rather  than  on  the  findings  of  exploration  with  probe  or  finger.  For 
instance,  it  is  better  to  enlarge  a  wound  of  the  abdominal  wall,  mider 
proper  surgical  conditions,  than  to  attempt  to  diagnosticate  perfora- 
tion of  abdominal  contents  by  means  of  a  probe.  The  extent  and 
character  of  hone  injuries  may  be  recognized  by  means  of  the  Ront- 
genogram. 

Treatment. — The  treatment  of  gunshot  wounds,  like  that  of  all 
wounds,  is  directed  toward  the  prevention  of  secondary  infection, 
and  the  creation  of  conditions  favoring  healing.  The  former  is  obvi- 
ated by  the  first  aid  dressing  and  by  refraining  froin  meddlesome  ex- 
ploration of  the  wound,  which  might  cause  infection.  The  wound 
should,  at  once,  be  covered  with  a  laj'er  of  sterile  gauze,  of  which 
each  soldier  should  be  supplied  with  a  package.  The  dressing  must 
be  applied  without  touching  the  wound  with  the  fingers.  Only  in 
cases  of  severe  bleeding  not  controllable  by  the  tourniquet,  and  in 
cases  of  threatened  suffocation,  when  immediate  tracheotomy^  becomes 
necessary,  is  it  justifiable  to  disregard  the  dangers  associated  with 
hasty  measures  of  relief. 

The  care  of  the  wound  is  carried  out  in  accord  with  the  rules 
governing  the  treatment  of  wounds  in  general.  During  the  cleansing 
and  disinfection  of  the  surfaces  contiguous  to  the  wound,  the  latter  is 
protected  by  means  of  a  gauze  pad  and  foreign  bodies  are  removed 
with  forceps.  "When  the  wound  is  small  and  a  "scab"  is  already 
formed,  this  may  be  left  undisturbed;  in  large  wounds  shreds  of 
tis:sue  and  particles  of  bone  should  be  removed  and  counterdrainage 
established  after  bleeding  is  arrested. 

Every  gunshot  wound  should  he  treated  hy  the  open  method.  The 
object  of  applying  sterile  or  iodoform  gauze  to  the  wounds  of  en- 
trance and  exit  is  to  favor  the  discharge  of  secretions  and  to  prevent 
the  entrance  of  infection.  In  this  way  gunshot  wounds  attended  with 
considerable  laceration  of  tissue  and  destruction  of  bone  may,  not  in- 
frequently, he  converted  into  simple  suhcutaneoiis  injuries.  In  cases 
of  extensive  ivounds  the  conditions  present  a  different  problem;  here, 
even  the  most  carefully  executed  tamponade  and  drainage  may  not 
succeed  in  obviating  the  occurrence  of  both  putrefactive  and  pyogenic 
infection,  secondary  hemorrhage,  and  tetanus.  "Wounds  of  this  sort 
are  necessarily  infected,  this  together  with  the  laceration  and  contusion 
of  the  soft  parts  results  in  the  severest  forms  of  necrosis  and  putre- 
factive processes.  In  cases  of  this  kind,  the  question  of  liheral  in- 
cision, early  resection  of  hones  and  joints,  and  of  amputation  must 


920     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

be  taken  into  account  with  the  view  of  saving  life.  This  is  especially 
true  in  military  surgery,  in  which  the  conditions  are  not  so  favorable 
for  the  close  study  of  the  indications  presented  and  the  opportunities 
to  exercise  elasticity  as  regards  treatment  as  obtains  in  civil  life. 

The  removal  of  projectiles,  indirect  projectiles  (fragments  of  bone, 
splinters  of  wood,  etc.),  and  portions  of  clothing  should  be  attempted 
only  when  they  are  visible  or  palpable,  when  infection  makes  their 
encapsulation  impossible,  or  when  the  latter  is  attended  with  pain  and 
interference  with  function. 

In  all  cases,  the  injured  part  should  be  immobilized  by  splints 
OR  BY  THE  GYPSUM  DRESSING  with  the  view  of  obviatiug  mechanical 
irritation.  This  rule  is  most  imperative  when  bones  or  joints  are 
injured,  but  should  also  be  conformed  to  in  cases  of  injury  of  the 
soft  parts,  especially  when  tendons  are  involved  or  when  a  hematoma 
is  present. 

In  cases  of  gunshot  wounds  of  organs  special  methods  of  procedure 
are  employed,  such  as  celiotomy  and  intestinal  suture,  trephining  for 
the  removal  of  bone  from  the  brain,  the  removal  of  ruptured  organs 
(spleen,  kidney,  etc.).  Here,  too,  the  procedure  in  military  surgery 
is,  of  necessity,  less  precipitate  than  in  civil  life,  first,  because  of  the 
conditions  under  which  operations  have  to  be  done  in  war ;  and,  sec- 
ond, because  gunshot  wounds  of  organs  are  frequently  followed  by 
spontaneous  recovery. 

The  first  aid  surgery  on  the  battlefield  is  restricted  to  covering  the 
wound  with  sterile  gauze,  the  temporary  arrest  of  hleeding,  and  the 
administration  of  agents  for  the  relief  of  syncope  and  shock.  Arrest 
of  bleeding  in  the  wound,  the  first  dressing  and  immobilization  of  the 
part  should  be  accomplished  in  quarters  properly  equipped  for  the 
purpose.  At  this  station  (main  dressing  station)  the  ligation  of  ar- 
teries, resections,  and  amputations  are  performed.  All  other  surgical 
procedures  should  be  carried  out  in  the  field  hospitals,  of  which  each 
army  corps  (40,000  men)  should  have  twelve  of  two  hundred  beds 
each. 


CHAPTER  IX 

CHEMICAL  INJURIES 

Chemical  substances  that  destroy  tissue  are  called  caustics.  The 
most  common  caustics  are  the  alkalies,  such  as  caustic  potassium,  so- 
dium, and  calcium ;  acids,  such  as  hydrochloric,  sulphuric,  nitric,  arse- 
nous,  chronic,  and  carbolic ;  and  the  salts  of  metals,  such  as  silvec 
nitrate,  zinc  chlorid,  and  copper  sulphate.  Acids  burn  the  tissues; 
the  destructive  action  of  the  alkalies  and  of  the  metallic  salts  is  due 
to  their  combining  with  albumin  and  the  dehydration  of  tissues. 

The  effect  of  mild  chemical  cauterization  is  inflammatory  in  char- 
acter, which  is  evinced  by  erythema  and  the  formation  of  vesicles,  a 
clinical  picture  similar  to  that  of  a  burn  of  the  firet  or  second  degree. 
The  prolonged  application  of  strongly  concentrated  caustics  is  fol- 
lowed by  eschar  formation  and  necrosis,  the  extent  of  which  depends 
upon  the  length  of  time  the  agent  remains  in  contact  with  the  tissues. 
As  a  rule  mucous  membranes  succumb  more  readily  than  the  skin. 

The  action  of  acetic  acid  is  superficial;  that  of  the  alkalies  is  in- 
variably deep.  Mucous  membranes  are  rapidly  destroyed  by  arsenic, 
chromic  and  lactic  acids,  ammonia  and  copper  sulphate.  Zinc  chlorid 
does  not  destroy  healthy  skin. 

Agents  which  slowly  destroy  the  tissues — such  as  sulphuric  and 
nitric  acid  and  silver  nitrate — are  largely  used  for  the  purpose  of 
therapeutic  cauterization.  Nitric  acid  is  often  used  to  destroy  super- 
ficial hemangiomas,  and  nitrate  of  silver  is  a  time  proved  agent  used 
for  the  destruction  of  exuberant  granulations.  Chromic  acid  is  used 
for  the  destruction  of  inoperable  malignant  tumors,  the  ulcerated  sur- 
face being  covered  with  a  twenty  to  fifty  per  cent  solution  of  the 
agent.  Lactic  acid  (fifty  to  eighty  per  cent)  is  used  in  cases  of 
tuberculosis  of  mucous  membranes.  Its  employment  is  at  times  fol- 
lowed by  a  severe  reaction. 

Symptoms. —  The  chief  symptom  of  chemical  cauterization  is  pain, 
which  may  be  transitory  (after  nitric  acid  or  silver  nitrate),  or  pro- 
longed (after  caustic  carbolic  acid  or  concentrated  lime).  The  area 
of  contact  is  white,  3^  ellowish  brown,  or  brown ;  the  skin  is  soon  trans- 

921 


922     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 


formed  into  a  dry  hard  crust ;  mucous  membrane  develops  a  soft  dis- 
colored spot.  The  necrosed  area  is  gradually  separated  by  the  forma- 
tion of  granulations.  Superficial  areas,  of  course,  separate  more 
rapidly  than  deep  ones;  when  the  bone  is  involved,  the  process  of 
separation  may  not  be  completed  for  several  weeks.  When  the  wall  of 
a  large  blood  vessel  becomes  necrotic,  separation  of  the  slough  is  likely 
to  be  complicated  by  severe  secondary  hemorrhage. 

Cicatrization  following  superficial  cauterization  leaves  the  skin 
smooth,  glistening,  and  soft.  When  there  has  been  destruction  of 
deeper  tissues,  repair  is  attended  with  the  formation  of  keloid  and 
deformity  due  to  cicatrical  contraction.  On  the  face,  the  latter  often 
results  in  narrowing 
the  normal  openings 
and  the  establishment 
of  ectropion  of  the 
eyelids  and  lips. 
Upon  hairy  surfaces 
the  destruction  of  the 
hair  bulbs  leaves  an 
unsightly,  bald,  shiny 
area. 

Cauterization  of  the 
esophagus  and  the 
urethra  is  frequently 
followed  by  cicatricial 
obliteration  of  their 
lumen.  The  former 
results  from  the  de- 
glutition of  caustics, 
which    often     causes 

perforation  of  the  stomach,  and  when  healing  occurs  is  frequently 
followed  by  deformity  of  the  stomach  or  by  pyloric  obstruction. 
Cauterization  of  the  urethra  is  most  often  caused  b}^  the  injections  of 
strong  solutions  of  silver  nitrate  used  for  the  purpose  of  obviating  the 
development  of  gonorrhea. 

The  eschar  following  chemical  cauterization  of  the  skin  is,  as  a  rule, 
easily  recognized.  The  reaction  of  the  destructive  agent  may  be  de- 
termined by  means  of  litmus.  The  patient  is  often  in  a  position  to 
throw  light  upon  this  aspect  of  the  situation. 

Treatment. — The  treatment  of  chemical  injuries,  in  recent  cases, 


Fig.  462. —  Cicatrization  Following  Chemical 
Burn. 


CHEMICAL  INJURIES  923 

eliould  be  directed  toward  neutralizing  the  causative  agent.  Acetic 
acid  may  be  copiously  used  for  neutralizing  the  caustic  alkalies  and  a 
solution  of  sodium  carbonate  may  be  applied  to  a  surface  upon  which 
acids  are  destructively  active. 

If  the  tissues  are  destroyed,  the  separation  of  the  eschar  may  be 
hastened  b}'  the  use  of  moist  dressings.  Pain  may  be  lessened  by  the 
application  of  ointments.  Cicatricial  contractions  should  be  subjected 
to  appropriate  surgical  efforts  at  relief.  Large  granulating  surfaces 
should  be  covered  with  skin  grafts. 


CHAPTER  X 

THEEMAL  INJURIES 

FREEZING 

The  action  of  cold  upon  tlie  body  is  attended  with  general  and 
constitutional  disturbances  which  are  grouped  under  the  general  head 
of  freezing.  The  exterit  of  the  pathological  changes  is  dependent  upon 
the  character,  the  time  of  exposure,  and  the  degree  of  cold,  in  con- 
junction with  the  constitutional  resistance  of  the  exposed  person  and 
the  local  resista^ice  of  the  part  involved. 

Cold  combined  with  moisture  acts  more  severely  than  dry  cold,  and 
resistance  to  still  cold  is  greater  than  when  low  temperature  is  com- 
bined with  high  wind.  Healthy  persons  are  more  resistant  to  extreme 
cold  than  are  enfeebled  ones  and  adults  bear  it  much  better  than 
children. 

General  Freezing. — General  freezing  begins  with  a  chill  and  a  feel- 
ing of  lassitude.  The  latter  is  especially  marked  when  the  exposure 
occurs  during  or  after  great  muscular  activity,  and  gradually  merges 
into  a  seductive  somnolence  which,  if  not  resisted,  results  in  death 
during  sleep.  The  most  frequent  victims  of  cold  are  drunken  per- 
sons, children,  the  aged  and  the  anemic.  As  freezing  progresses  the 
afflicted  person  reels,  the  sensorium  becomes  benumbed,  respiration 
and  pulse  are  slowed,  and  unconsciousness  gradually  supervenes.  As 
a  rule  death  results  promptly  from  cardiac  failure  and  cerebral 
anemia,  but  may  occur  slowly  (after  several  days),  the  outcome  of 
exhaustion  and  the  abolition  of  all  metabolic  processes;  ultimately 
all  the  fluids  of  the  hody  are  frozen. 

If  the  rectal  temperature  of  the  exposed  person  is  not  below  20° C. 
(68 °F.)  resuscitation  is  possible  even  though  the  cardiac  and  respira- 
tor}^ activities  are  at  low  ebb.  In  severe  cases  recovery  is  slow  and  is 
likely  to  be  attended  with  grave  disturbances  of  the  central  nervous 
system  (headache,  unconsciousness,  delirium,  paralysis).  During  this 
time  death  may  occur  suddenly  from  degeneration  of  the  red  blood 
corpuscles  or  from  cardiac  failure. 

924 


THERMAL  INJURIES  925 

Treatment. — The  treatment  is  directed  toward  a  gradual  reestah- 
lishment  of  the  body  temperature  and  the  maintenance  of  the  circu- 
lation. Sudden  increase  in  temperature  involves  the  danger  of  the 
entrance  into  the  circulation  of  a  large  number  of  disintegrated  ery- 
throcytes and  a  consequent  fatal  outcome.  Therefore,  the  patient 
should  not  at  once  be  placed  in  a  warm  chamber,  but  should  be  kept  in 
an  atmosphere  a  few  degrees  above  freezing,  and  rubbed  with  snow  or 
cold  wet  towels  with  the  view  of  increasing  the  peripheral  circulation. 
During  this  time  the  heart  is  sustained  with  hypodermic  injections  of 
camphor  and  artificial  respiration  may  be  resorted  to.  After  this  the 
patient  is  immersed  in  a  bath  at  a  temperature  of  16°C.  (60°F.) 
which  is  gradually  (at  the  end  of  three  hours)  increased  to  30 °C 
(86°F.) .  When  deglutition  is  possible  warm  stimulants  ma}'  be  given. 
If  this  is  not  feasible,  warm  saline  solution  and  whisky  may  be  intro- 
duced into  the  rectum.  The  reestablishment  of  the  peripheral  circula- 
tion is  often  attended  with  severe  pain  and  may  demand  the  use  of 
morphia. 

Local  Freezing. — Local  freezing  often  involves  unprotected  portions 
of  the  body  and  tlie  extremities,  especially  when  these  are  covered  by 
tightly  fitting  articles  of  apparel  (gloves  and  shoes)  which  interfere 
with  the  circulation.  For  this  reason  the  vase,  the  ears,  the  cheeks, 
the  fingers,  and  the  toes  are  often  frozen. 

Local  freezing  is  divided  into  three  degrees :  Hyperemic,  vesicular, 
and  gangrenous.  The  last  may,  according  to  extent,  be  subdivided  into 
necrosis  of  the  superficial  skin,  the  skin  and  .subcutaneous  tissues, 
and  all  of  the  soft  parts  down  to  the  bone.  This  would  create  five 
degrees  of  freezing,  to  which  may  be  added  a  peculiar  form  of  chronic 
freezing  called  chilblains. 

The  first  degree  of  freezing  (congelatio  erythematosa)  is  the  one 
most  commonly  seen.  It  occurs  in  connection  with  relatively  short  ex- 
posure and  is  characterized  by  redness  and  swelling  as  soon  as  the  tem- 
perature of  the  part  is  reestablished.  During  the  period  of  exposure  a 
tingling  of  the  sliin  is  at  first  experienced,  followed  by  complete  loss 
of  sensation,  attended  with  arrest  of  the  circulation  and  pallor.  "When 
the  part  is  warmed,  the  blood  vessels  dilate  (hyperemia),  and  when 
the  vessels  are  damaged,  localized  edema,  occurs.  Anesthesia  and  hy- 
peremia persist  in  proportion  to  the  time  of  exposure,  though  rarely 
longer  than  ten  days.  At  times,  the  tip  of  the  nose  and  the  rims  of 
the  ears  are  permanently  reddened  as  the  result  of  paralysis  of  the 
blood  vessels. 


926     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

The  second  degree  of  freezing  is  attended  with  dark  red  or  violet 
discoloration,  pallor  and  anesthesia  of  the  skin,  and  the  formation  of 
hlehs  (congelatio  bullosa).  In  this  form  of  the  aifliction  the  circula- 
tion is  arrested  in  the  smaller  veins  because  the  arteries  do  not  possess 
sufficient  contractility  to  force  the  blood  into  the  larger  veins.  A^enous 
stasis  is  followed  by  transudation  of  plasma  which  results  in  edema, 
elevation  of  the  epidermis,  and  the  formation  of  hlchs.  The  contents 
of  the  blebs  usually  are  tinged  with  blood  but  may  be  purely  serous 
in  character,  "When  the  circulation  is  reestablished,  the  blebs,  as  a 
rule,  form  crusts  beneath  wdiich  epidermization  takes  place  and  no 
scarring  remains.  When,  however,  the  blebs  are  ruptured,  suppura- 
tive inflammation  occurs  and  this  is  attended  with  obstinate  edema  and 
prolonged  idceration. 

The  third  degree  of  freezing  is  called  frost  gangrene  (congelatio 
escharotica) .  The  tissues  become  gangrenous  when  the  circulation  has 
been  excluded  for  a  long  time,  when  the  blood  vessels  are  thrombosed, 
or  when  an  artery  of  considerable  size  is  obstructed  by  the  formation 
of  a  thrombus  at  the  edge  of  the  frozen  zone.  In  this  class  of  eases 
the  frozen  part  becomes  brittle  and  rigid  so  that  small  areas,  such  as 
the  tip  of  the  nose  and  the  rims  of  the  ears,  maj'  be  broken  off  like 
pieces  of  glass.  AVhen  the  part  is  warmed  it  may  at  first  present  the 
edema,  cyanosis,  and  bleb  formation  of  the  second  degree ;  however, 
the  area  remains  cold,  blue,  and  anesthetic,  showing  that  the  circula- 
tion is  not  reestablished.  In  a  few  days  shreds  of  skin  and  the  finger 
nails  begin  to  separate,  or  insular  areas  of  the  skin  (finger  tips,  nose, 
ears,  etc.)  form  dark  brown  crusts,  expressive  of  greater  or  lesser 
degrees  of  mummification,  surrounded  by  a  zone  of  redness  which 
indicates  the  line  of  demarcation. 

The  three  degrees  of  freezing  may  coexist  when  several  parts  of 
the  body  are  involved  and  the  exposure  has  not  been  the  same  in  each 
instance.  Severe  cases,  with  frost  gangrene  of  all  the  extremities, 
are  usually  attended  with  sjTnptoms  of  general  freezing.  Distinction 
with  respect  to  the  degree  of  involvement  is  not  possible  at  once, 
as  the  extent  of  the  damage  to  the  tissues  may  not  become  manifest 
until  several  days  after  the  exposure. 

Local  freezing  is  not  attended  with  constitutional  disturbances 
unless  infection  of  a  necrotic  area  occurs.  The  character  of  an  in- 
fection under  these  conditions  does  not  differ  from  that  occurring  in 
connection  with  wounds  o£  other  kinds. 


THERMAL  INJURIES  927 

The  sequelae  of  local  freezing  are  persistent  cyanotic  edema  asso- 
ciated with  painful  ulceration,  contractures  of  fingers  and  toes,  and 
cicatricial  deformities  of  the  deep  soft  parts  and  of  the  skin.  Trans- 
ient, persistent,  and  permanent  paralysis  of  peripheral  nerves  occurs 
in  some  cases,  and  myogenous  contracture,  due  to  degeneration  of 
muscles,  is  not  uncommon.  In  severe  cases,  obliteration  of  the  lumen  of 
arteries  by  the  proliferation  of  connective  tissue  of  the  intima  causes 
disturbances  of  nutrition  attended  with  chronic  ulceration  and 
necrosis. 

Treatment. — The  treatment  of  local  freezing  consists  of  gradual 
warming  of  the  part.  Sudden  thawing  causes  severe  pain  and  dam- 
ages the  tissues. 

In  mild  cases  the  part  may  be  rubbed  with  snow  or  ice  until  the 
circulation  is  reestablished. 

Indians,  lumbermen,  prospectors,  etc.,  in  northwest  Canada,  where 
frost  bites  are  common,  have  found  that  oil  of  turpentine  is  the  best 
application  in  all  stages.  The  part  is  kept  soaked  with  the  fluid  and 
the  results  are  reported  as  phenomenal  (Rose  and  Carless^). 

In  severe  cases  the  indication  is  to  ohviate  circulatory  stasis  as  soon 
as  possible,  with  the  view  of  preventing  necrosis.  This  is  best  accom- 
plished by  elevating  the  frozen  limh  to  the  vertical  position  and  immo- 
hilizing  it  in  splints.  In  this  way  the  veins  are  unburdened  and  the 
arterial  flow  of  blood  flushes  out  the  capillaries. 

The  utility  of  the  measure  has  been  proved  hy  practical  experience. 
In  this  stage  of  the  condition,  the  use  of  passive  hyperemia  is  posi- 
tively contra-indicated. 

When  the  chronic  sequelae,  as  shown  b}^  edematous  and  cyanotic 
swelling  due  to  paralysis  of  the  blood  vessels,  are  present,  the  artificial 
arterial  hyperemia  advised  by  Ritter-  is  of  signal  service.  For  the 
purpose,  the  hot  air  apparatus  of  Bier  may  be  effectually  employed. 
The  limb  may  be  placed  in  the  apparatus  for  one  hour,  followed  by 
massage  and  cold  douches. 

In  all  cases  the  frozen  part  should  be  cleansed  and  dressed  asepti- 
cally  with  the  view  of  preventing  the  entrance  of  infection.  Ruptured 
hlehs  and  partially  detached  shreds  of  epidermis  should  be  removed. 
Adherence  of  the  dressings  to  raw  surfaces  may  be  prevented  b}'  the 
use  of  a  layer  of  zinc  vaselin  which  is  changed  as  soon  as  the  dressing 
is  saturated  with  exudate. 

While  demarcation  is  developing,  secondary  infection  is  prevented 
by  the  exercise  of  the  usual  rules  governing  aseptic  wound  treatment. 


928     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

Amputation  should  be  postponed  until  demarcation  has  occurred, 
unless  evidence  of  constitutional  infection  develops.  In  cases  of  dry 
gangrene  of  the  fingers  and  toes  and  of  restricted  areas  of  the  face, 
separation  of  the  necrotic  portion  may  be  awaited  and  secondary 
repair  made. 

The  red  or  purple  discoloration  of  the  nose,  following  frost  bite,  is, 
at  times,  very  persistent  and  causes  the  patient  much  chagrin  for 
obvious  reasons.  In  these  cases  Riedinger^  advises  the  injection  of 
ergotiu.  Needling,  the  injection  of  small  quantities  of  alcohol,  and 
the  electrolj'tic  needle  all  serve  a  useful  purpose. 

Chilblains  (perniones)  are  chronic  inflammatory,  usually  circum- 
scribed, swellings  of  the  skin  due  to  paralysis  of  blood  vessels,  severe 
transudation  and  inflammatory  proliferation  of  the  skin  and  subcu- 
taneous tissues. 

They  occur  most  frequently  on  the  hands  and  feet  (especially  on 
the  extensor  side  of  the  joints,  the  outer  edge  of  the  foot,  and  on  the 
heel),  more  rarely  on  the  face,  occasionally  on  the  penis,  and  are  due 
to  repeated  mild  local  freezing,  especially  in  wet  weather  from  fre- 
quent soaking  of  the  foot  attire,  or  when  the  hands  are  constantly 
submerged  in  cold  water  during  the  winter  (laundresses,  cooks). 
Young,  anemic  persons,  especially  chlorotic  girls,  are  susceptible. 

Chilblains  are  characterized  by  an  itching  and  burning  nodular 
infiltration  of  the  skin,  which  is  bluish  red  in  color  and  presents  a 
glistening  surface.  They  disappear  in  summer  and  recur  each  winter, 
unless  exposure  to  cold  is  avoided  or  the  patient's  general  condition 
improves. 

"When  the  lesion  is  subjected  to  irritation  (friction,  scratching,  pres- 
sure of  the  boot,  etc.),  the  chilblain  becomes  covered  with  pustules, 
which  often  break  down,  forming  frost  ulcers,  deep  rhagades,  or  the 
entire  area  may  suppurate;  the  last  is  likely  to  be  followed  by  more 
or  less  extensive  scarring. 

The  treatment  of  chilblain  consists  of  measures  tending  to  improve 
the  circulation,  such  as  warm  baths,  alcohol  packs,  the  application  of 
tincture  of  iodin,  and  mild  counterirritants  (mercurial  or  silver  oint- 
ment). The  use  of  hot  air  is  beneficial.  Attention  should  be  paid  to 
cleanliness,  and  infection  prevented  by  the  application  of  protective 
dressings.  The  recurrence  of  chilblains  may  be  ginsx^mtfiibMvPjplKDpier 
clothing,  avoidance  of  tight  boots  and  glovesQtJ^icou^'fllr^'dtigraDfcilBS 
hand^/'thf  i&efoft!PublieirgilfeY!efir^9an,(i.fat^«fetiofi  to  th'e\g«mis^^eiidMon 
g^fa^aiQmictaftirdiolaAoiio^.pgliients.yo'o  i^/ilin  Imirirf  oift  io  saio'iezo  odi  xd 


.   THERMAL  INJURIES  929 


BURNS 


The  action  of  high  degrees  of  heat  upon  the  body  causes  disturbances 
called  hums. 

Burns  are  caused  by  radiating  heat  (sun  rays,  open  fires),  flames, 
molten  metals  or  superheated  solid  bodies,  boiling  water,  hot  fluids, 
hot  steam,  and  gases.  The  effect  of  chemical  caustics  is  similar  to 
that  of  heat. 

The  effect  of  heat  varies  with  its  form;  for  instance,  radiating  heat 
produces  erythema  or  vesicles,  while  contact  with  a  red  hot  metal 
produces  an  eschar ;  it  is  also  dependent  upon  the  time  of  the  exposure 
and  the  degree  of  hea't  with  which  the  contact  is  made.  The  local 
effect  of  heat  is  divided  into  three  degrees :  Hyperemia  or  erythema, 
the  formation  of  vesicles,  and  eschar  formation.  A  fourth  degree 
called  carhonization  is  a  severe  form  of  eschar  formation. 

First  Degree  Burn. —  The  first  degree  of  burn  {conhustio  erythema- 
tosa) is  characterized  by  the  appearance  of  a  symmetrical,  dark  red 
area  due  to  dilatation  of  the  blood  vessels,  pain  which  gradually 
increases  and  then  slowly  disappears,  and  moderate  sivelling  attended 
w^th  a  sensation  of  tension.  Sunburn  is  the  simplest  form  of  this 
degree  of  burn  {erythema  solare).  First  degree  burn  always  coexists 
in  cases  of  the  more  severe  forms. 

The  redness  usually  disappears  in  a  few  days,  leaving  a  brown  dis- 
coloration which  gradually  fades  as  the  superficial  layers  of  the  skin 
exfoliate  in  the  form  of  glistening  scales. 

"When  the  skin  is  again  exposed  to  radiating  heat,  vesicles  consisting 
of  the  horny  layer  are  produced,  and  are  likely  to  form  more  or  less 
extensive  crusts.  Repeated  exposures  result  in  persistent  brownish 
discoloration  of  the  skin,  interspersed  with  small  areas  of  pigmenta- 
tion (freckles). 

The  pain  and  tension  of  sunburn  is  relieved  by  the  application  of 
ointments  (zinc  ointment,  vaselin,  etc.).  The  occurrence  may  be 
prevented  by  covering  the  skin  with  ointment  before  exposing  it  to  the 
sun 's  raj^s. 

Second  Degree  Burn. —  Second  degree  burn  {comhustio  hullosa)  is 
distinguished  by  the  appearance  of  Mehs  within  an  area  of  redness  and 
sivcUing  of  the  skin.  The  blebs,  which  vary  in  size  and  appear  in 
from  a  few  hours  to  the  next  day  after  exposure  to  heat,  contain  a 
clear  serous  or  slightly  yellowish,  cloudy  fluid.  In  some  instances  the 
contents  of  a  bleb  consist  of  a  gelatinous  coagulum  located  between 


930     INJURIES  TO  SOFT  PARTS,  BOXES  AND  JOINTS 

the  layers  of  the  skin.  Removal  of  a  bleb  exposes  the  red,  extremely 
sensitive  corium,  which  presents  a  favorable  port  for  the  entrance  of 
infection. 

When  the  contents  of  a  bleb  are  absorbed,  the  latter  shrinks  and 
forms  a  ihin  crust  which  is  spontaneously  exfoliated  at  the  end  of  a 
week,  leaving  a  new  horny  layer  of  the  skin  furnished  by  the  rete 
Malpighii.  A  flat  glistening  scar  occurs  only  when  the  corium  is 
destroyed. 

Burns  of  this  sort  are  attended  with  severe  pain  which  usually  per- 
sists until  the  redness  and  swelling  disappear,  i.  e.,  after  three  or 
four  days. 

As  a  rule  second  degree  burns  are  produced  by  scalding  or  by 
momentary  contact  with  a  flame.  The  latter  cause  ma}'  be  recognized 
b}'  the  presence  of  charred  hairs. 

The  treatment  of  second  degree  burns  is  directed  toward  lessening 
pain  and  the  creation  of  conditions  favoring  cpidermization.  The 
former  is  accomplished  by  immohilization  of  the  part  by  means  of 
splints,  the  application  of  a  protective  dressing,  and,  when  necessary, 
the  use  of  morphia.  The  dressing  should  be  arranged  to  allow  of  the 
formation  of  a  crust,  which  latter  is  readily  attained  when  infection 
does  not  occur.  The  use  of  ointments,  wet  dressings,  or  immersion  of 
the  part  favors  infection,  macerates  the  tissues  and  delays  repair. 

Thorough  cleansing  of  the  injury  is  impracticable,  as  manipulations 
to  this  end  are  likely  to  rupture  the  vesicles,  therefore  the  part  should 
be  gentl}'  lavaged  with  sterile  w-ater  and  dried  with  alcohol. 

Ruptured  vesicles  should  be  removed  with  the  view  of  giving  egress 
to  infection.  This  procedure  is  executed  by  means  of  forceps  and 
scissors.  Intact  vesicles  which  are  distended  may  be  drained  b}'  means 
of  a  slender  scalpel  introduced  near  the  base  and  allowed  to  remain 
in  contact  with  the  underlying  skin.  Smaller  vesicles  are  not 
disturbed. 

After  cleansing,  a  dressing  of  dry  gauze  may  be  applied  to  the 
burned  surface,  the  inner  layer  of  which  becomes  fastened  in  place  by 
the  secretions  and  need  not  be  disturbed  during  subsequent  dressings ; 
it  is  ultimately  thrown  off  with  the  scab  (healing  under  a  scab). 
Yon  Bardeleben*  uses  gauze  into  the  meshes  of  which  a  powder  of 
equal  parts  of  bismuth  subnitrate  and  starch  has  been  incorporated ; 
a  measure  of  considerable  value.  In  this  way  the  burn  is  protected, 
the  secretions  are  absorbed,  and  the  dressing  next  the  skin  is  sponta- 
neouslv  exfoliated  at  the  end  of  one  or  two  weeks.     Wlien  the  secretion 


THER^IAL  INJURIES  931 

from  the  wound  is  excessive  and  is  not  taken  up  by  the  dressing,  the 
latter  is  saturated  with  sterile  oil,  carefully  removed  and  renewed. 
The  injured  part  should  be  immobilized  in  splints  with  the  view  of 
preventing  trauma  from  contraction  of  muscles. 

In  hums  of  the  face  it  is  often  possible  to  cause  encrustation  by  the 
simple  use  of  sterile  bismuth  and  starch  powder,  beneath  which  heal- 
ing rapidl}^  takes  place.  In  this  class  of  cases  the  dry  powder  treat- 
ment is  preferable  to  the  application  of  oil  and  lime  water. 

Third  Degree  Burn. —  The  third  degree  of  burn  {copihustio  escJiaro- 
iica)  is  characterized  by  the  formation  of  an  eschar.  The  action  of 
the  heat  (especially  contact  with  glowing  solids  or  with  the  flame) 
destroys  the  tissues,  which  take  on  the  form  of  a  hard,  insensible, 
yellowish  brown  or  black  mass.  Ultimately  the  eschar  is  separated 
from  the  healthy  tissue  by  a  process  of  granulation. 

As  a  rule,  the  necrosed  area  is  surrounded  by  a  zone  exhibiting  first 
and  second  degree  burns.  During  separation  of  the  slough,  local  and 
systemic  and  pyogenic  and  putrefactive  infection  is  likelj^  to  occur 
and  at  times  deeply  extending  necrosis  results  in  the  exposure  of  joint 
surfaces  or  erosion  into  large  blood  -vessels.  The  latter  is  attended 
with  more  or  less  secondary  hemorrhage.  Prolonged  suppurative 
processes  incident  to  the  separation  of  necrotic  tissue  may  cause 
amyloid  degeneration  of  the  vital  organs. 

After  the  necrosed  tissue  is  separated  a  granulating  surface  is  ex- 
posed. As  healing  progresses,  there  is  a  tendency  toward  the  forma- 
tion of  keloid  and  the  occurrence  of  deformity  from  cicatricial 
contraction  (Fig.  463).  The  latter  is  not  alone  offensive  from  a 
cosmetic  standpoint,  but  often  interferes  with  function.  The  face  and 
neck  present  the  most  objectionable  features  in  this  connection,  the 
deformity  resulting  in  ectropion  of  the  lids  and  lips  and  contractures 
of  the  neck.  In  the  groin,  axilla,  elbow,  and  the  flexor  side  of  the 
wrist,  cicatricial  contractures  often  seriously  interfere  with  function. 
The  constant  irritation  of  surfaces  of  this  sort  causes  persistent  ulcer- 
ation and,  not  rarely,  is  the  cause  of  carcinoma. 

The  treatment  of  third  degree  burns  may  be  carried  out  in  the  same 
manner  as  is  that  of  second  degree,  and  an  effort  may  be  made  to 
permit  separation  of  the  slough  to  take  place  in  this  way.  However, 
the  process  is  usually'  attended  with  excessive  secretion  demanding 
frequent  changes  of  dressing,  which  is  painful  and  likely  to  traumatize 
the  tissues  and  destroy  the  remnants  of  skin  that  have  escaped  destruc- 


932     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

tion  by  heat.     In  cases  in  which  encrustation  is  impracticable,  the 
so-called  modern  treatment  of  burns  will  be  found  very  effective. 
Wax  Treatment. —  The  modern  treatment  of  burns  consists  of  coat- 


FiG.  463. —  Cicatricial  Adhesions  between  the  Arm,  Thorax,  and  Back 
Following  Scalding. 


ing  the  injured  area  with  material  which  excludes  the  air ;  it  is  easily 
and  painlessly  removed,  and  may  be  renewed  at  frequent  intervals. 
Its  greatest  field  of  usefulness  is  in  severe  second  and  third  degree 


THERMAL  INJURIES 


933 


burns.  For  the  purpose  the  surface  is  cleansed  and  dried  as  stated 
and  then  covered  with  a  layer  of  paraffin  mixture.  The  formula  of 
paraffin  most  extensively  used  is  that  of  HulP :  Resorcin,  one  per 
cent ;  oil  of  eucalyptus,  two  per  cent ;  olive  oil,  five  per  cent ;  paraffin 
molle,  twenty-five  per  cent ;  paraffin  dura,  sixty-seven  per  cent.  The 
paraffin  dura  and  molle  are  melted  and  the  olive  oil  is  added,  then 
the  resorcin,  after  it  has  been  dissolved  in  absolute  alcohol  (soluble 
in  2.1  per  cent),  and  the  eucalyptus  oil  added  when  this  mixture  has 
cooled  to  55°C.  (131°F.).  Beta-naphthol  may  be  substituted  for 
resorcin. 

The  burn  is  covered  with  a  layer  of  paraffin  at  a  temperature  of 

50°C.  (122°F.)  using 
a  broad  camel's  hair 
brush  for  the  purpose. 
In  the  British  army 
the  mixture  is  sprayed 
on  the  burned  surface 
by  means  of  the  ap- 
paratus .shown  in  Fig. 
464. 

A  slab  of  the  par- 
affin preparation  is 
placed  in  the  appara- 
tus and  heated,  either 
over  a  spirit  lamp  or 
in  a  water  bath,  to  the 
temperature  at  which  it 
melts  (48°C.-119°F.). 
The  bellows  of  the 
spray  producer  are  then  adjusted  and  the  liquid  paraffin  is  pumped 
in  a  very  fine  spray  onto  the  burnt  surface. 

In  either  case  the  first  layer  of  paraffin  is  covered  with  a  thin  layer 
of  cotton  wool  and  the  whole  is  again  covered  with  a  laj'er  of  the 
mixture  applied  with  a  brush.  The  dressing  is  completed  b}^  appl3'ing 
cotton  wool  and  a  bandage.  The  burns  are  usually  dressed  daily. 
Sloughs  are  not  interfered  with  at  the  first  dressing;  at  the  second 
dressing  the  dead  tissues  are  cut  away.  The  experience  of  the  w^riter 
bears  out  the  claim  for  the  efficiency  of  the  treatment.  It  relieves 
pain,  the  dressing  is  changed  without  discomfort,  and  repair  is 
conserved. 


Fig.  464. —  Paraffin  Spray  (Medical  and  Surgi- 
cal Therapy). 


934     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

When  granulation  is  established,  epidermal  transplantation  should 
be  executed  at  once,  a  measure  which  frequently  obviates  cicatricial 
deformation.  "When  cicatricial  contraction  occurs,  complete  excision 
of  the  scar  tissue  and  transplantation  of  slin  must  be  resorted  to ;  nor 
should  this  be  delayed  any  longer  than  is  consistent  with  the  con- 
ditions. In  extensive  lesions  repeated  plastic  operative  measures  of 
relief  may  be  necessary.  In  some  instances  in  which  operative  meas- 
ures are  contra-indicated,  an  attempt  may  be  made  to  soften  the  scar 
tissue  by  injection  of  thiosinamin  (see  keloid). 

Secondary  jDhlegmon  which  occurs  during  separation  of  the  slough 
should  be  freely  incised,  and  when  general  infection  supervenes  ampu- 
tation may  become  necessary. 

Carhonization  is  seen  in  cases  in  which  death  occurs  from  great  heat, 
as  in  mine  explosions  or  when  buildings  are  consumed  by  flames.  At 
times  an  entire  limb  is  carbonized  as  the  result  of  contact  with  molten 
metal.  In  these  instances  the  injured  part  is  converted  into  a  hlack, 
friable  mass,  a  condition  which  demands  early  amputation. 

General  symptoms  in  burns  occur  only  when  the  area  involved  is 
extensive  and  when  infection  supervenes.  However,  even  mild  cases 
are  attended  with  more  or  less  elevation  of  temperature  and  moderate 
alhuminuria  (due  to  disintegration  of  albumin). 

When  more  than  one  half  of  the  surface  of  the  body  is  burned  grave 
constitutional  disturbances  are  manifected  irrespective  of  the  degree 
of  burn,  and,  as  a  rule,  are  followed  by  a  fatal  outcoriie.  The  involve- 
ment of  one  third  of  the  body  i^  also  not  infrequently  fatal,  either  at 
the  end  of  a  few  days,  or  after  prolonged  pyogenic  and  putrefactive 
infection. 

Severely  hurned  persons  are  usually  conscious  and  do  not  seem  to 
realize  the  seriousness  of  their  condition ;  they  are  restless,  toss  from 
side  to  side,  suffer  from  thirst,  and  beg,  sometimes  piteously,  for  relief 
from  pain.  The  uninjured  skin  is  pale  and  cool,  the  temperature 
being  two  or  three  degrees  below  the  normal.  This  is  believed  to  be 
due  in  part  to  the  radiation  of  heat  from  the  surface  where  the  epi- 
dermis is  destroyed  and  in  part  to  cardiac  failure.  Vomiting  is  re- 
garded as  an  unfavorable  prognostic  symptom.  In  a  few  hours  apathy 
and  subconsciousness  develop.  The  pulse  becomes  small  and  thread}-, 
rcspiratimi  superficial  and  rapid.  Vomiting,  diarrhea,  cyanosis, 
delirium,  clonic  convulsions,  coma  and  collapse  sequentiall}^  close  the 
picture.     The  urine  is  scanty  and  terminates  in  anuria.     Toward  the 


THERMAL  INJURIES  935 

end  tlie  temperature  iu  the  rectum  rises  rapidly,  though  the  surface 
heat  is  below  the  normal. 

Fostmortem  examination  following  death  from  burns  (other  than 
cases  of  secondary  infection)  is  unsatisfactory.  The  vital  organs  and 
the  meninges  are  usually  found  in  a  condition  of  venous  hyperemia. 
The  brain  is  edematous;  the  gastric  mucosa,  the  muscles,  and  the 
serous  membranes  are  ecchymotic.  In  a  number  of  instances,  the 
duodenum  is  ulcerated  as  the  result  of  thrombosis  and  the  digestive 
action  of  the  gastric  juice.  At  times,  the  kidneys  undergo  parenchy- 
matous degeneration. 

Opinions  as  to  the  cause  of  death  are  widely  divergent.  Death  at 
an  early  period  is  attributed  to  paralysis  of  the  ganglia  of  the  central 
nervous  system,  especially  the  medulla  (Marchand*').  Death  at  more 
or  less  remote  periods  is  ascribable  to  a  variety  of  causes.  It  has  been 
charged  to  destruction  of  the  red  Mood  corpuscles  and  to  changes  in 
the  kidneys  due  to  the  action  of  the  toxic  end  products  of  metabolism. 
Sonnenberg'^  suggests  that  death  is  caused  by  shock,  causing  the  reflex 
lowering  of  the  tone  of  the  blood  vessels  and  consequent  "heart 
block."  Extensive  capillary  thrombosis  due  to  degenerated  blood  cells 
is  believed  to  be  an  important  factor  in  some  instances.  Considerable 
importance  is  attached  to  the  theory  that  the  plasma  is  reduced  in 
quantity.  Many  observers  consider  that  the  absorption  of  toxic  sub- 
stances (of  unknown  character)  is  the  causative  factor  in  fatal  cases 
(Wilms^).  Others  believe  that  the  toxins  cause  a  chemical  change  in 
the  albuminoids  of  the  various  Antal  organs,  especially  the  brain.  H. 
Pfeiffer°  and  He^'de^^  seem  to  have  shown  that  the  disintegration  of 
tissue  at  the  site  of  the  burn  is  attended  with  the  liberation  of  toxic 
protein,  split  products  which  have  the  character  of  a  peptone,  and 
that  these  are  concerned  in  producing  an  action  similar  to  anaphylaxis 
(p.  182). 

In  the  treatment  of  extensive  burns,  the  indications  are  to  take  care 
of  the  burned  surface,  to  arrest  pain  by  the  use  of  opiates,  to  sustain 
the  circulation  by  the  injection  of  camphor,  etc.  (see  collapse),  to 
introduce  fluids,  and  to  promote  the  excretion  of  toxic  substances. 
The  last  two  indications  are  best  met  by  the  liberal  introduction  of 
physiological  salt  solution  into  the  rectum  or  directl}^  into  a  vein  in 
the  arm.  When  large  surfaces  of  skin  are  destroj-ed  the  radiation  of 
heat  may,  in  a  measure,  be  compensated  for  by  warming  the  bed,  and 
by  the  use  of  warm  blankets,  hot  water  bags,  etc.,  as  is  done  in  the 
treatment  of  shock  (p.  945). 


936     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

X-Ray  Burns. —  X-ray  burns  are  caused  by  too  close  contact  with 
the  tube  and  by  too  long  or  too  frequent  exposure  to  the  ray.  The 
condition  may  be  acute  or  chronic;  neither  form  becomes  manifest 
immediately  upon  the  exposure  but  appears  about  a  week  later.  Dur- 
ing this  time  a  slight  erythema  may  occur,  but  there  is  no  pain  or 
other  sensory  disturbances ;  nor  is  there  any  evidence  of  the  destruc- 
tive action  of  the  ray  during  the  exposure,  a  fact  which  for  a  long 
time  led  to  unfortunate  experiences,  especially  in  instances  in  which 
early  workers  in  this  field  operated  in  the  zone  of  the  ra}'  without 
adequate  protection. 

The  acute  lesions  correspond  to  the  various  degrees  of  ordinary 
burns,  i.  e.,  moderate  exposures  produce  erythema;  longer  ones, 
vesicles,  which  latter  are  attended  with  considerable  pain ;  prolonged 
exposure  is  followed  by  necrosis  of  skin  and  exceedingly  painful  ulcer- 
ation; slight  exposure  results  in  falling  of  hair.  Repair  is  accom- 
plished at  the  end  of  several  weeks.  The  hairs  are  replaced  in  from 
six  to  eight  weeks ;  the  ulcerated  areas  cicatrize  and,  in  some  instances, 
the  skin  remains  atrophic  at  the  site  of  the  vesicles. 

Chronic  lesions  are  seen  in  radiographers  and  consist  of  dystrophy 
of  the  skin  (Kienbock^^),  characterized  by  atrophy  of  the  glands  of 
the  skin,  alopecia,  abnormal  pigmentation,  friability  of  the  nails,  and 
painful  and  progressive  ulceration,  to  which  at  times  carcinoma  is 
added.  In  severe  cases,  endarteritis  obliterans  develops,  which  results 
in  mummification  of  the  part  (Miilisam^-).  Similar  conditions  are 
provoked  by  the  action  of  radium  (Halkin^^),  though  these  are  rarely 
as  severe  as  obtains  in  connection  with  X-ray. 

The  treatment  of  X-ray  burns  is  similar  to  that  of  burns  produced 
by  other  causes. 

Electric  Burns. —  The  injuries  produced  by  an  electric  current  are 
the  result  of  various  conditions  and  usually  follow  contact  with  highly 
charged  conducting  elements,  such  as  the  main  feed  wire  leading  to 
many  terminals.  Not  infrequently  the  injur}'  follows  contact  with  a 
broken  cable  or  occurs  while  repairing  a  conducting  element  without 
excluding  it  from  circuit. 

Contact  may  be  direct,  such  as  happens  when  grasping  a  cable  with 
the  hands,  or  by  its  broken  end  falling  on  the  patient ;  or  the  electrical 
discharge  may  gain  access  to  the  body  indirectly  through  metallic 
substances,  such  as  pliers,  telephone  or  telegraph  wires,  etc.  Accord- 
ing to  Schumacher,^*  inclusion  in  the  electric  circuit  occurs,  first,  when 
the  body  comes  directly  or  indirectly  in  contact  with  both  conducting 


THERMAL  INJURIES  937 

elements  of  the  circuit;  second,  when  direct  or  indirect  contact  is 
established  with  one  conducting  element  and  the  current  "grounded" 
through  the  body ;  and  third,  when  the  electrical  contact  occurs  by  a 
spark.  In  some  instances,  the  electrical  current  may  traverse  the  body 
when  contact  is  made  simultaneously  with  two  points  of  a  single  con- 
ducting element,  but  this  is  rarely  followed  by  serious  consequences. 

The  injured  person  is  usually  rendered  unconscious  by  the  electrical 
discharge;  at  times,  muscular  contraction  causes  contact  to  be  main- 
tained with  the  conducting  element,  and  at  others  the  bod}^  is  forcibly 
propelled  away  from  it.  Unconsciousness  may  be  transient ;  however, 
in  most  instances  the  electrical  shock  causes  paralysis  and  convulsions, 
and  it  may  be  followed  by  a  period  of  restlessness  or  of  somnolence.  In 
severe  cases,  the  disturbances  of  the  nervous  system  soon  merge  into 
coma,  and  death  ensues. 

Local  injuries  consist  of  the  various  degrees  of  hums  of  the  skin. 
Punctured  wounds,  not  unlike  those  produced  by  projectiles,  are  pro- 
duced at  the  point  of  entrance  and  exit  of  the  electric  current.  "When 
the  conducting  element  remams  in  contact  for  a  long  time  deep  de- 
struction of  tissue  takes  place  and  portions  of  limb  may  be  charred 
off  in  this  way.  Strange  to  say,  w^ounds  of  this  sort  are  not  attended 
with  pain ;  however,  the  extent  of  tissue  necrosis  is  always  great  and 
is  astonishingly  disproportionate  to  the  area  visibly  involved  at  first. 
An  acute  edema  is  always  present  and  is  believed  to  be  due  to  paralysis 
of  the  blood  vessels.  Autopsy  reveals  numerous  minute  hemorrhages 
in  the  gray  matter  of  the  brain  and  cord  (Jellinek^^). 

The  destructive  action  of  the  electrical  current  is  dependent  lipon  a 
number  of  factors,  of  which  the  time  of  its  contact,  its  course,  strength, 
tension,  and  the  resistance  of  the  bod}^  are  the  most  important. 
Momentary  contact  with  a  powerful  current  may  not  produce  any  evil 
effects.  In  a  general  way  it  may  be  said  that  a  current  of  one  ampere 
(strength)  and  a  tension  of  over  500  volts  may  be  fatal.  On  the  other 
hand,  weak  currents  with  high  tension  do  not  harm.  This  is  shown 
in  connection  with  the  current  used  for  producing  the  X-ray  (1/1,000 
ampere  and  100,000  volts).  Under  these  conditions  the  resistance  of 
the  skin  (200,000  ohms)  is  an  important  factor.  The  strength  of  the 
current  traversing  the  body  must  be  calculated  in  accord  with  the  law 
of  Ohm,  i.  e.,  tension  being  determined  by  resistance.  This  explains 
the  severe  local  injury  following  contact  with  dry  skin  (a  poor  con- 
ductor) and  the  disproportionately  severe  systemic  effect  when  the 
skin  is  wet   (a  good  conductor).     For  instance,  a  current  of  5000 


938     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

volts,  traversing  the  body  at  a  resistance  of  50,000  ohms,  develops  a 
strength  of  0.1  amperes;  the  same  5,000  volts  meeting  a  resistance  of 
5,000  ohms  (when  the  skin  is  wet)  develops  1.0  ampere.  While  the 
alternating  current  is  stronger  than  the  direct,  it  is  less  dangerous  the 
more  frequent  the  alternations,  and  is  almost  harmless  when  the 
polarity  changes  100,000  times  per  second  (Tesla  current). 

The  effect  of  the  electrical  current  upon  the  body  varies  greatly  in 
character.  First,  the  electrical  action  attacks  primarily  the  nervous 
system  (molecular  disturbances,  cellular  destruction,  and  degenera- 
tion) causing,  in  accord  with  the  strength  of  the  current,  paralysis  of 
the  vital  centers,  unconsciousness,  motor  paralyses,  convulsions,  and 
sensory  disturbances.  Second,  the  mechanical  effect  of  the  current  is 
shown  by  propulsion  of  the  body  away  from  the  conducting  element. 
Jcllinek^^  attributes  this  to  muscular  contraction,  the  outcome  of  in- 
voluntary defensive  action.  Third,  the  thermal  effect  exercises  an 
influence  on  the  caloric  development  in  the  body.  When  resistance  is 
greater  than  the  capacity  to  conduct,  a  part  of  the  electrical  energy 
is  converted  into  heat.  Under  these  conditions  the  usual  thermic 
injury  does  not  act  from  without,  but  acts  upon  the  deeper  tissues  as  a 
w^hole  and  causes  changes  in  the  cellular  elements.  These  changes 
constitute  the  fourth  action  of  the  electric  current,  which  is  expressed 
by  cellular  disintegration,  degeneration  and  necrosis  of  tissue,  and  the 
liberation  of  certain  toxic  substances.  This  electrical  damage  to  tissue 
accounts  for  the  necrosis  and  ulceration  sequential  to  electrical  burns. 

Lightning  Stroke. —  Injuries  produced  by  lightning  bear  a  resem- 
blance to  those  caused  by  contact  with  electric  currents.  As  a  rule, 
the  afflicted  person  is  instantly  killed  as  the  result  of  paralysis  of  the 
respiratory  and  cardiac  centers. 

When  the  stroke  is  not  fatal  the  picture  is  that  of  severe  cerelral 
concussion.  The  stricken  person  is  rendered  unconscious,  the  skin  is 
cold  and  pale,  the  pulse  is  often  absent  and,  w^hen  perceptible,  is 
usually  slow,  respiration  is  superficial,  the  limbs  relaxed,  and  sensory 
conduction  is  abolished.  Recovery  is  gradual,  extending  from  over 
twenty-four  hours  to  several  weeks.  In  some  instances,  the  acute 
condition  is  followed  by  a  more  or  less  protracted  period  of  mental 
unrest  and  motor  paralysis;  all  of  which,  however,  ultimately  dis- 
appear. The  same  picture,  but  in  a  lesser  degree,  is  presented  by 
persons  close  to  the  point  where  the  lightning  strikes. 

At  times,  the  tearing  effect  of  lightning  avulses  an  entire  limb  or 
inflicts  extensive  lacerated  wounds.     More  or  less  severe  injuries  may 


THERMAL  INJURIES  939 

be  produced  when  persons  are  hurled  to  the  ground  by  the  force  of 
the  lightning. 

Burns  produced  hy  lightning  appear  at  the  point  of  impact,  at  the 
port  of  exit,  and  along  the  route  the  electric  fluid  takes.  At  the 
former  site,  the  wound  is  round,  deep,  and  surrounded  by  a  black 
edge ;  an  appearance  not  unlike  that  of  a  gunshot  wound.  From  this 
numerous  irregular  (''zigzag")  stripes  radiate  in  all  directions,  the 
result,  according  to  Jellinek,^^  of  paralysis  of  the  blood  vessels,  and, 
at  times,  correspond  to  subcutaneous  hemorrhages.  Where  the  cloth- 
ing is  closel}'  apposed  to  the  body,  and  in  situations  corresponding  to 
metal  buttons,  coins,  etc.,  the  injury  takes  on  the  form  of  a  third 
degree  burn. 

The  treatment  is  directed  toward  combating  the  respiratory  and 
cardiac  disturbances.  In  severe  cases  operative  exposure  and  massage 
of  the  heart  would  seem  to  be  justified  (Schumacher^^).  Ordinarih', 
the  usual  cardiac  stimulants  and  the  employment  of  artificial  respira- 
tion accomplish  the  purpose.  Burns  are  treated  in  the  manner 
described  in  connection  with  these  injuries  from  other  causes. 

Sunstroke  and  Heat  Stroke. —  Sunstroke  and  heat  stroke  are  char- 
acterized by  menacing  increase  of  the  body  temperature. 

Sunstroke. —  Sunstroke  is  the  direct  effect  of  the  sun 's  rays  upon 
the  body,  especially  upon  the  exposed  head  in  persons  who  work  bare 
headed  or  sleep  in  the  sun.  The  affliction  is  preceded  by  severe 
cephalalgia,  dizziness,  tiniiitus  aurium,  and  scintillations,  which  are 
soon  followed  by  unconsciousness  and  convulsions.  The  face  is  red- 
dened, the  skin  is  hot,  the  purse  is  rapid  and  at  first  boimding,  but  soon 
becomes  feeble.  The  temperature  may  rise  to  42° C.  (107°F.).  Death 
occurs,  during  unconsciousness,  in  a  few  hours  from  heart  failure. 
In  less  severe  cases,  recovery  takes  place  when  the  bod}'  is  cooled  b}' 
means  of  baths,  spray,  or  cold  wet  packs.  Autopsy  reveals  marked 
h}T)eremia  of  the  meninges  and  edema  of  the  brain. 

Heat  Stroke. —  Heat  stroke  is  the  result  of  increased  genera- 
tion   OF    HEAT    IN    THE    BODY    WHEN    RADIATION    IS    LESSENED.      In    the 

tropics  heat  stroke  may  be  easily  provoked  by  lessening  radiation. 
Muscular  effort  is  a  contributing  causative  factor  (Musehold^®). 

Heat  stroke  occurs  most  often  in  persons  who  undergo  great  'physical 
exertion  in  a  warm,  humid,  still  atmosphere,  and  whose  attire  does  not 
permit  of  ready  radiation  of  heat. 

The  prodroraa  of  heat  stroke  consist  of  copious  perspiration,  malaise, 
nausea,  and  thirst.     These  are  soon  followed  by  cephalalgia,  dizziness. 


940     INJUKIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

a  feeling  of  apprehension,  and  vomiting.  Speech  becomes  incoherent, 
the  eyes  dull,  locomotion  is  incoordinate,  and  finally  unconsciousness 
supervenes.  The  face  is  dusky  and  cyanotic,  the  pulse  very  rapid, 
thready,  or  imperceptible.  The  heart  sounds  are  distant  and  irregu- 
lar, respiration  superficial  and  rapid,  the  skin  dry  and  hot,  the  cloth- 
ing saturated  with  sweat.  The  temperature  rises  to  40-41°  C.  (104- 
106 °F.)  or  more,  the  reflexes  are  reduced  or  absent,  the  pupils  contract 
and  do  not  react  to  light.  Presently,  general  clonic  convulsions  occur 
and  the  muscles  of  mastication  and  those  of  the  back  become  rigid. 

About  seventy  per  cent  of  the  cases  die  in  a  few  hours  from  heart 
failure,  the  rest  slowly  regain  consciousness,  though  complete  recovery 
is  preceded  by  a  more  or  less  protracted  period  during  which  cephal- 
algia, dizziness,  loss  of  memory,  mental  disturbances  and  cardiac 
insufficiency  occur. 

Autopsy  reveals  a  picture  not  unlike  that  of  suffocation.  The  en- 
gorgement of  the  venous  system,  contraction  of  the  left  ventricle,  and 
the  dilatation  and  distention  of  the  right  heart  suggest  that  the  fatal 
outcome  is  due  to  cardiac  paralysis.  According  to  Senftleben^'^  the 
hemaglobin  liberated  from  the  blood  corpuscles,  destroyed  in  great 
numbers,  causes  the  splitting  off  of  fibrin  ferment,  so  that  coagulation 
of  the  blood  takes  place,  especially  in  the  capillaries  of  the  lung,  and 
the  blood  no  longer  gains  access  to  the  left  heart. 

The  treatment  of  sunstroke  consists  of  immediate  lessening  of  the 
tody  temperature  and  stimidation  of  the  heart.  Artificial  respiration 
and  the  injection  of  camphor  is  indicated  in  severe  cases.  The  patient 
should  be  disrobed  and  placed  in  a  cold  hath  or  sprayed  with  cold 
water,  special  attention  being  paid  to  the  head.  Fluids  should  be 
freely  administered  by  mouth  or  introduced  into  a  vein  in  the  form 
of  saline  solution. 

During  the  prodromal  stage  the  patient  is  placed  in  the  recumbent 
position  in  a  cool  place  and  cooling  drinks  freely  administered.  Sun 
and  heat  stroke  may  be  avoided  by  appropriate  clothing,  the  liberal 
use  of  cool  drinks  and  the  avoidance  of  alcoholic  beverages. 

BIBLIOGRAPHY 

1.  Rose  and  Carless.     London  and  New  York,  1914. 

2.  RiTTER.     Miinch.  med.  Woch.,  1907. 

3.  RiEDiNGER.     Arch.  f.  klin.  Chir.,  Bd.  20,  1877. 

4.  v.  Bardeleben.     Dentseh.  med.  Woeh.,  1892. 

5.  Hull.     Brit.  Med.  Jr.  i,  1917. 

6.  Marchand.    Krehl  and  Marchand  Handb.  d.  AUg.  Path.  Bd.  i,  1908. 


THERMAL  IxXJURIES  941 

7.  Soxjs-EXBERG.     Deutsch.  Chir.,  1879,  with  lit 

8.  _\\  iLAis.     .Aiitteil  aus  den  Greuzgeb.  j.  Med.  u.  Cliir.  Bd.  8,  19J1,  with  lit 

Rf'if  ^Vai7""'^'''"  ^''^-  ^^-  1^0,  1905,  also  Zeits^hr.  f.'  Ixnmui;: 
Ha.  iU,  1911. 

10.  Heyde.     Med.  Ivlinik,  1912,  No.  7. 

11.  KiEXBOCK.     Wieu  med.  Presse,  1901,  Xo    18 

12.  MuHSAM.     Arch.  f.  klin.  Chir.  Bd.  74,  1904. 

13.  Halkix.     Arch.  f.  Dermat.  und  Syj^h.'Bd.  15,  1903 

14.  Schumacher.     Wiesbaden,  1908. 

15.  Jellixek.     Electropatholooy,  Stuttgart,  1903. 

lb.     Musehold.     Eulenburg's  Realenc-yl.   (3d  ed.)  Ixxiv,  1904.  with  lit 
17.     SENKTLEBEi^.    Berliji.  klin.  Woch ,  19o7 


CHAPTER  XI 

GENERAL  EFFECTS  OF  INJURY 

Collapse,  syncope,  and  shock  are  closely  allied  conditions  which  fol- 
low injury,  but  may  occur  from  other  causes  and  are  characterized  by 
transient  or  fatal  lessening  of  the  vital  functions.  The  three  con- 
ditions are  due  to  closely  associated  causative  factors  and  one  may 
merge  into  another. 

Collapse. —  Collapse  may  be  defined  as  an  exhaustion  of  the  vital 
forces,  the  doniinent  factor  of  which  is  paralysis  of  the  heart. 

The  causes  of  collapse  are  severe  hemorrhage  complicating  injuries 
or  surgical  operation;  injuries  of  the  heart;  overexertion  of  the 
heart,  especially  in  cases  of  disease  of  the  valves,  the  cardiac  muscle 
fiber,  or  the  circulatory  sj'stem;  sudden  increase  of  the  vis  a  fronte, 
such  as  the  obstruction  of  a  large  branch  of  the  pulmonary  artery  by 
an  embolus;  sudden  cerebral  anemia,  the  result  of  embolic  obstruction 
of  a  cerebral  artery  or  from  precipitate  assumption  of  the  erect  pos- 
ture during  narcosis;  chemical  poisoning  (snake  poison,  prolonged 
narcosis,  etc.)  and  bacterial  intoxication  which  produce  paralysis  of 
the  vascular  centers. 

The  manifestations  of  collapse  are  pallor  or  cyanosis  of  the  face, 
cold  perspiration,  cold  —  usually  cyanotic  —  extremities,  dilated 
pupils,  small,  rapid,  barelj^  perceptible,  irregular  pulse,  mild  delirium 
with  subsultus  at  intervals,  superficial  breathing  (rapid  or  slowed) 
followed  by  dulled  consciousness,  vomiting,  and  subnormal  tempera- 
ture (even  in  the  course  of  a  febrile  affliction).  These  symptoms 
appear  in  rapid  sequence  and  are  followed  by  a  fatal  outcome  unless 
the  heart  is  effectually  sustained. 

The  latter  is  best  accomplished  by  the  subcutaneous  injection  of  oil 
of  camphor  (1  c.cm,  of  a  ten  per  cent  solution)  at  half  hour  intervals 
or  the  subcutaneous  and  intravenous  introduction  of  0.9  per  cent 
sodium  chlorid  solution.  The  latter  method  is  especially  indicated  in 
collapse  from  loss  of  blood  (p.  51).  In  addition  to  this,  the  admin- 
istration of  alcohol  in  the  form  of  brandy,  etc.,  the  application  of  heat, 

942 


GENERAL  EFFECTS  OF  INJURY  943 

the  lowering  of  the  head  and  the  elevation  of  the  lower  extremities 
may  be  employed. 

Syncope. —  Syncope  may  be  described  as  a  transitory  disturbance  of 
consciousness  due  to  reflex  cerebral  anemia,  the  result  of  psychic 
influences.  It  commonly  occurs  in  impressionable  women  and  in 
chronic  alcoholics. 

Syncope  is  caused  by  temperamental  influences,  such  as  fear  or 
horror,  especially  when  the  particular  occurrence  is  exaggerated  by 
an  imaginative  mind.  It  often  occurs  when  persons  of  this  sort  see 
surgical  instruments  or  blood,  or  are  frightened  by  the  manipulations 
of  the  surgeon.  It  is  generally  believed  that  emotions  of  this  nature 
act  upon  the  vasomotor  system  which  produces  cerebral  anemia. 

The  period  of  unconsciousness  in  s;^^lcope  is  usually  preceded  by 
pallor,  nausea,  cold  sweat,  dizziness,  yawning,  and  loss  of  vision. 
Presently  the  eyes  becomes  set,  the  pupils  dilate,  and  unconsciousness 
supervenes.  The  pulse  is  accelerated  (slowing  of  the  pulse  is  not 
infrequent)  and  small,  but  is  usually  regular;  respiration  is  slow  and 
superficial.  Rapid  return  to  consciousness  is  the  rule.  A  fatal  out- 
come is  exceedingly  rare. 

The  treatment  consists  of  lowering  the  head  and  trunk,  w^hich  is 
promptly  followed  by  return  to  consciousness.  The  recumbent  posi- 
tion should  be  maintained  until  the  various  functions  reassume  the 
normal.  In  severe  cases  the  treatment  taken  up  in  connection  with 
collapse  may  be  necessary. 

Shock. —  Shock  may  be  defined  as  a  reflex  depression  of  the  vital 
forces,  resembling  collapse.  The  indefiniteness  of  this  characterization 
is  apparent,  yet,  despite  the  mass  of  literature  devoted  to  the  subject, 
there  does  not  seem  to  be  any  justification  for  a  more  lucid  one. 

Most  authors  assume  that  peripheral  impressions  are  capable  of 
exhausting  or  inhibiting  the  centers  located  in  the  medulla  and  spinal 
cord  which  control  the  various  functions,  so  that  the  activities  of  the 
heart,  respiratory  organs,  vasomotor  nerves,  sensory  and  motor  con- 
ductors, and  the  reflexes  are  interfered  with.  This  view  is  supported 
by  the  experimental  demonstration  that  shock  does  not  occur  in  ani- 
mals in  which  the  conductivity  of  the  spinal  cord  is  abolished  by 
various  agents  (cocain,  magnesium  sulphate,  etc.),  and  that  its  appear- 
ance may  be  delayed  in  the  same  way.  Not  a  few  observers  believe 
that  reflex  vasomotor  paralysis  is  responsible  for  shock.  The  vaso- 
motor paralysis  causes  the  veins  in  the  splanchnic  area  to  become 
filled  with  blood  and  the  general  blood  pressure  falls  to  such  a  degree 


944     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

that  the  nervous  system  becomes  anemic.  Finally,  the  circulatory 
disturbances  result  in  cessation  of  the  heart's  action.  There  is  no 
doubt  that  irritation  of  sensory,  splanchnic,  and  other  sympathetic 
nerves  and  branches  of  the  pneumogastric  are  factors  in  cardiac 
inhibition. 

The  causation  of  shock  relates  primarih'  to  forceful  concussion  of 
large  zones  of  distribution  of  sensory  nerves,  the  result  of  trauma, 
and  secondly,  to  influences  exerted  upon  certain  restricted  nerve  areas. 
In  this  way  shock  follows  injuries  that  are  the  result  of  crushing 
forces,  such  as  are  produced  in  railroad  accidents,  or  by  artillery 
projectiles,  and  the  extensive  destruction  of  tissue  by  heat  or  cold. 
In  cases  of  concussion  of  the  thorax  the  fibers  of  the  vagus  are  trauma- 
tized and  shock  is  likely  to  be  severe.  When  the  abdomen  is  subjected 
to  trauma,  or  when  intestinal  or  gastric  perforation  occurs,  a  similar 
condition  is  produced  by  irritation  of  the  terminal  nerves  in  this 
region.  The  former  explains  the  frequency  of  shock  following  pro- 
longed manipulation  of  the  gut  during  celiotomy.  Manipulations  of 
the  vas  during  herniotomy  are  often  attended  with  an  astonishing 
degree  of  shock  (Short^). 

General  debility,  h^^perirritability,  and  anemia  predispose  to  the 
occurrence  of  shock. 

The  manifestations  of  shock  may  be  characterized  as :  a  rapid 
lessening  of  the  vital  forces,  together  with  depression  of  cardiac  activ- 
ity, moderate  lowering  of  temperature,  irregular  respiration,  and 
inhibition  of  the  functions  of  the  spinal  cord  with  respect  to  motion, 
sensation  and  the  reflexes  without  loss  of  consciousness  (SammeP). 
In  the  lighter  forms  the  skin  is  pale  and  cold ;  the  patient  is  apathetic 
or  restless ;  reflexes  are  lowered ;  motion  is  impaired ;  the  pulse  is 
small,  thready,  and  more  often  slow  than  rapid ;  and  respiration  is 
superficial.  The  severe  form  exhibits  cadaveric  pallor  and  cyanosis  of 
the  lips,  cheeks,  and  limbs.  The  entire  body  is  bathed  in  sweat;  the 
pupils  are  dilated,  and  respond  slowly  or  not  at  all ;  the  eyeballs  are 
rigid;  hiccough  and  vomiting  occur;  the  pulse  is  slow,  feeble,  and 
fluttering ;  respiration  is  superficial  and  interrupted  by  occasional 
deep  inspiration ;  the  temperature  is  slightly  below  normal ;  reflexes 
are  lessened  or  absent ;  and  frequently  there  is  incontinence  of  urine 
and  feces.  Unconsciousness  does  not  occur,  although  there  is  a  lower- 
ing of  cerebral  activity. 

The  severe  forms  of  shock  may  be  divided  into  the  apathetic,  which 
is  characterized  by  the  picture  just  presented,  and  the  erethistic,  which 


GENERAL  EFFECTS  OF  INJURY  945 

is  attended  with  restlessness,  apprehension,  and  insomnia,  together 
with  the  usual  manifestations  common  to  the  former.  One  form  may 
merge  into  the  other. 

Psychic  shock  is  a  term  applied  to  the  sudden  appearance  of  the 
phenomena  attendant  upon  the  milder  forms  of  shock  when  caused  by 
fright,  fear,  good  news,  sudden  and  unexpected  excitation  of  the  seri- 
sorium  —  for  instance,  by  a  shot  fired  in  close  proximity.  It  is  differ- 
entiated from  syncope  by  the  fact  that  it  is  not  accompanied  by 
unconsciousness. 

Shock,  even  in  the  milder  forms,  often  terminates  fatally.  This 
outcome  occurs  most  frequently  when  shock  is  complicated  by  extensive 
bleeding.  Recovery  is  usually  evident  in  a  few  hours ;  i.  e.,  if  improve- 
ment is  not  apparent  at  this  time,  a  fatal  outcome  is  to  be  expected. 

The  question  of  whether  the  picture  following  severe  injury  is  due 
to  persistence  of  shock,  to  progressive  internal  bleeding,  or  to  the 
beginning  of  infection,  is  a  complex  problem,  the  solution  of  which 
rests  upon  close  observation  of  the  pulse,  the  temperature,  and  the 
blood  findings.  In  a  general  way  it  may  be  said  that,  if  the  manifes- 
tations OF  SHOCK  DO  NOT  DISAPPEAR  IN  A  FEW  HOURS,  IT  IS  FAIR  TO 
ASSUME   THAT    INTERNAL   BLEEDING    OR    INFLAMMATION    IS   PRESENT    and 

that  operative  effort  at  relief  is  justifiable. 

Lessening  of  the  body  temperature  and  changes  in  the  quality  of  the 
pulse,  despite  the  use  of  appropriate  measures  of  relief,  are  of  grave 
prognostic  significance. 

In  the  treatment  of  shock  physiological  rest  is  the  most  important 
consideration  (Crile^).  This  is  accomplished  by  management  of  the 
patient  and  his  environment.  Painful  manipulations,  other  than 
those  caused  by  the  dressing  of  injuries,  should  be  avoided.  Massage, 
mustard  plasters,  etc.,  should  not  be  employed.  Anodynes  may  be 
used  in  small  doses.  In  addition  to  this,  the  heart  may  be  stimulated 
by  the  use  of  camphor,  adrenalin,  etc.  If  the  usual  methods  are  un- 
availing, 1  c.cm.  of  adrenalin  chlorid  (1:1,000)  added  to  500  c.cm.  of 
saline  solution  may  be  administered  by  hypodermoclj'sis.  In  extreme 
cases  a  continuous  infusion  of  1 :20,000  adrenalin  solution  at  the  rate 
of  2  c.cm.  per  minute  may  be  used  (Crile^).  In  certain  cases  one  of 
the  methods  of  blood  transfusion  may  be  emploj-ed  (p.  47).  Gum 
solutions  also  have  proved  useful. 

Narcosis  and  operative  procedures  should  be  postponed  until  reac- 
tion occurs;  however,  this  general  rule  may  be  disregarded  in  urgent 
cases. 


946     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

Intravenous  infusion  of  salt  solution  should  be  used  only  ■when  the 
lowering  of  the  blood  pressure  is  due  to  hemorrhage. 


BIBLIOGRAPHY 

1.  Short.     Brit.  Jr.  of  Surg,  i,  1911. 

2.  Sammel.     Eulenberg's  Realencycl.,  1898,  xvni. 

3.  Crile.     Boston  Med.  and  Surg.  Jr.,  1908. 


CHAPTER  XII 

DELIEIUM  TREMENS 

Chronic  alcoholics  (the  so-called  steady  drinkers)  frequently 
develop  delirium  tremens  following  severe  injuries  or  after  operations. 
While  it  is  generally  believed  that  brandy  and  whisky  drinkers  are 
more  often  ati'ected  than  those  habituated  to  the  so-called  lighter  alco- 
holic beverages,  it  would  seem  that  the  excessive  use,  and  more 
especially  the  prolonged  use,  of  any  form  of  alcohol  may  stand  in  a 
•causative  relationship  to  the  condition. 

The  prodroma,  which  usually  appear  in  the  first  few  days,  consist 
of  restlessness  and  insomnia,  tremor  of  the  hands  and  tongue  and  great 
irritability.  The  patient  mutters  to  himself,  picks  at  the  bedclothes 
and  dressings ;  soon  hallucinations  develop,  the  patient  sees  animals  of 
all  kinds  in  the  room,  on  the  walls,  and  on  the  bed,  which  he  tries  to 
push  away  or  begs,  sometimes  piteously,  to  have  removed.  Illusions 
are  also  present,  the  patient  mistaking  his  room  for  a  prison  and  the 
attendants  for  jailers.  As  the  condition  progresses,  delusions  of  per- 
secution occur,  during  whose  continuance  the  patient  becomes  violent 
and  is  likely  to  do  himself  great  harm;  as  sensory  conduction  is 
lessened  or  absent,  the  site  of  the  injury  is  often  severely  traumatized 
(such  as  walking  on  an  amputated  stump  or  compound  fractured 
limb). 

The  great  menace  in  delirium  tremens  relates  to  the  heart  which, 
in  chronic  alcoholics,  is  usually  the  site  of  fatty  degeneration.  The 
additional  strain  of  the  exertion  incident  to  the  delirium  often  results 
in  sudden  collapse  and  death.  In  less  severe  cases,  the  patient  falls 
into  a  deep  slumber  at  the  end  of  several  days  of  delirium  and  recovers 
without  any  recollection  associated  with  the  period  of  delirium. 

When  sleep  produced  by  hypnotics  is  followed  by  return  of  the 
delirium,  the  prognosis  is  unfavorable.  The  outlook  is  also  serious 
when  wound  infection  and  pneumonitis  develop,  complications  which 
are  not  rare. 

Most  observers  believe  that  the  complete  withdrawal  of  alcohol  from 

947 


948     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

chronic  alcoholics  after  the  receipt  of  a  severe  injury  or  following 
operation,  predisposes  to  delirium  tremens;  a  belief  that  the  writer 
shares.  Indeed,  care  is  taken  to  introduce  alcohol  into  the  rectum 
when  administration  by  mouth  is  not  possible.  It  is  also  the  practice 
of  the  writer  to  administer  alcohol  during  the  so-called  prodromal 
stage  of  the  disease.  On  the  other  hand,  not  a  few  withdraw  the 
alcohol  when  the  symptoms  have  developed,  in  the  belief  that  it  has 
no  influence  in  controlling  them. 

The  exact  cause  of  delirium  is  not  clear.  It  is  probable  that  toxic 
irritation  of  the  cerebral  centers  is  an  important  element,  an  assump- 
tion that  has  led  to  the  belief  that  infection,  pulmonary  inflammation, 
and  fat  embolism  are  concerned  in  producing  the  clinical  picture, 
rather  than  the  withdrawal  of  alcohol. 

The  treatment  consists  of  the  administration  of  opiates  {morphin, 
scopolamin)  and  of  antispasmodics  {chloral  and  hromids),  together 
with  cardiac  stimulants. 

The  wounded  part  should  be  encased  in  gypsum  with  the  view  of 
preventing  additional  trauma  during  the  delirium.  Isolation  in  a 
quiet,  darkened  chamber  and  the  constant  watchful  care  of  a  skilled 
attendant  are  helpful  measures.  Restraint  should  be  judiciously 
employed  and  avoided  if  possible. 


CHAPTER  XIII 

FAT  EMBOLISM 

The  presence  of  fat  globules  in  the  urine  following  severe  injuries, 
especially  those  involving  extensive  solution  of  continuity  of  bone, 
indicate  that  these  are  not  infrequently  attended  with  the  entrance  of 
particles  of  fat  into  the  circulation. 

Clinical  Manifestations. —  Clinical  manifestations  of  fat  embolism 
are  rare  and  would  seem  to  depend  upon  the  quantity  of  fat  gaming 
access  to  the  circulation.  The  extent  of  injury  to  the  bone  does  not 
seem  to  be  the  important  factor,  as  fatal  results  have  followed  from 
this  cause  in  cases  of  simple  fracture  of  the  fibula,  the  patella,  and  the 
external  malleolus.  Indeed,  actual  destruction  of  the  bone  tissue  does 
not  seem  to  be  necessary  according  to  Ribbert^  who  was  able  to  produce 
fatal  fat  embolism  in  animalS'  by  prolonged  percussion  of  the  exposed 
tibia.  Fritzsche"  attributes  considerable  importance  to  general  con- 
cussion of  the  osseous  system  as  a  causative  factor.  However,  fat 
embolism  does  occur  in  connection  with  operative  osteotomy,  especially 
when  hrisement  force  is  used,  and  ankylosed  joints  are  forcibly  mobil- 
ized, particularly  if  manipulations  of  this  sort  are  executed  after  pro- 
longed disuse  has  led  to  fatt}^  infiltration  of  the  bones.  It  is  fair  to 
assume  that  fat  globules-  gain  access  to  the  blood  when  traumatized 
bone  is  pressed  against  the  walls  of  veins  (Bergemann^). 

Symptoms. —  Symptoms  of  fat  embolism  appear  as  soon  as  large 
quantities  of  globuli  reach  the  internal  organs  and  cause  occlusion 
of  the  small  blood  vessels  and  the  capillaries.  As  is  to  be  expected, 
emboli  first  invade  the  lung,  which  usually  occurs  during  the  first 
days  after  the  injury,  resulting  in  dyspnea  and  hemoptysis  conse- 
quent to  the  formation  of  infarcts.  When  the  emboli  lodge  in  the 
smaller  arteries  of  the  lung  and  are  not  carried  into  the  capillaries, 
the  disturbances  are  restricted  to  those  stated,  as  the  fat  does  not 
reach  the  general  circulation.  In  a  certain  number  of  cases,  however, 
the  capillaries  become  filled  and  the  globules  are  carried  to  the  other 
organs,  of  which  the  "brain  and  heart  are  most  severely  affected.     In. 

949 


950     INJURIES  TO  SOFT  PARTS,  BONES  AND  JOINTS 

this  event,  the  symptoms  of  cerebral  invasion  (somnolence,  delirium, 
jactitation,  vomiting,  paralysis,  and  coma)  and  those  of  acute  cardiac 
failure  (because  of  degeneration  of  heart  fiber)  are  added  to  the 
clinical  picture.  Fever  is  frequent  and  may  be  due  to  inflammation 
in  the  lungs  or  to  circulatory  disturbances  in  the  heat  centers,  though 
the  latter  may  also  be  expressed  by  a  subnormal  temperature. 

In  severe  cases  death  occurs  in  a  few  days ;  in  the  milder  cases,  the 
symptoms  may  gradually  disappear  as  the  fat  is  absorbed,  and  re- 
covery take  place. 

Diagnosis. — The  diagnosis  of  fat  embolism  during  life  may  be  made 
when  the  lung  and  brain  symptoms  appear  soon  after  a  hone  in  jury, 
in  cases  in  which  the  latter  is  not  attended  with  other  complications 
and  when  fat  globules  are  present  in  the  urine.  Pulmonary  embo»- 
lism  following  fractures  occurs  much  later,  several  weeks  after  receipt 
of  the  injury. 

In  fatal  cases  the  presence  of  fat  emboli  ma}^  be  recognized  in 
organs  examined  soon  after  death.  Schridd  and  Schmorl*  have 
demonstrated  the  presence  of  punctate  hemorrhages  and  of  minute 
ulcers  in  the  mucosa  of  the  stomach,  in  cases  of  this  sort. 

Treatment. — The  treatment  of  fat  embolism  consists  of  efforts  to 
sustain  the  heart.  For  the  purpose  Schanz^'  advises  the  use  of  saline 
infusion,  which  dilates  and  flushes  out  the  capillaries  at  the  same  time. 

With  the  view  of  preventing  the  occurrence  of  fat  embolism  in 
connection  with  bone  operations,  v.  Arberle*^  advises  that  the  v.  Es- 
march  constriction  be  gradually  loosened.  Following  experimental 
work,  Reiner^  suggests  that,  after  embolism  has  been  established,  the 
puncture  and  aspiration  of  blood  from  a  large  afferent  vein  may  be 
of  service.  In  any  event,  the  forceful  manipulation  of  atrophic  bones 
should  be  avoided,  and,  in  operations  upon  bones,  the  saw  should  take 
the  place  of  chisel  and  mallet  as  much  as  possible. 

BIBLIOGRAPHY 

1.  RiBBERT.     Deutsch.  med.  Woch.,  1900. 

2.  Fritzsche  (Wilms).     Deutsch.  Zeitsclir.  f.  Chir.  Bd.  107,  1910. 

3.  Bergemanx.     Berlin,  klin.  Woch.,  1915,  with  lit. 

4.  Schridd  and  Schmorl.     Verb.  d.  path.  Gesel.,  Sept.  1907. 

5.  SCHANZ.     Zentrbl.  f.  Chir.,  1910. 

6.  V.  Arberle.     Orthoped.  Kens:.,  1907. 

7.  Reixer.    Zentrbl.  f.  Chir.,  1907. 


CHAPTER  XIV 
TEAUMATIC  DIABETES 

Disturbances  of  sugar  metabolism  and  of  the  mechanism  of  the 
excretion  of  urine  occur  after  injuries  of  all  kinds,  but  are  especially 
connected  with  trauma  to  the  brain,  fractures,  and  injuries  of  the 
liver  and  kidneys.  As  a  rule,  the  symptoms  disappear  in  a  few  days 
after  the  injury.  In  most  instances,  the  quantity  of  sugar  excreted  is 
small  (one  per  cent)  ;  however,  at  times  diabetes  melUtus  and  insipidus 
persist  for  a  long  time. 

The  explanation  of  traumatic  diabetes  is  not  known  at  this  time. 
Its  treatment  is  of  course  properly  not  discussed  in  a  work  of  this  sort. 


961 


PART  V 

SURGICAL  DISEASES  OTHER  THAN  INFECTIONS  AND 

TUMORS 


CHAPTER  I 


SURGICAL  DISEASES  OF  THE  SKIN 


Congenital  Malformations  of  the  Skin. — Congenital  defects  of  the 
skin  are  numerous  and  are  due  to  disturbances  in  development.  They 
consist  of  clefts  and  fistulcB,  the  result  of  failure  of  coalescence  of 
embryonic  folds  and  pf  coadhesion  of  contiguous  portions  of  the  body. 

To  the  latter  class  belong  the 
eases  of  cutaneous  syndactylism, 
in  which  contiguous  fingers  are 
inclosed  in  the  same  cutaneous 
sheath  (Fig.  465),  or  are  con- 
nected by  means  of  a  weblike  area 
of  skin  (Fig.  466),  and  the  so- 
called  wing  flaps  found  in  the 
popliteal  space,  the  axilla,  and 
neck  (Bauscli^). 

The  small  cutaneous  nodules 
found  in  various  portions  of  the 
body  and  the  deep  furrows  seen 
upon  the  face  and  the  extremities 
are  due  to  embryonic  adhesion  of 
the,  amnion.  The  latter  are  at 
times  responsible  for  complete 
amputation  of  a  limb  in  utero. 

The  nodules,  fistulae,  and  fur- 
rows   may    be    removed    by    ex- 
cision.   More  extensive  malforma- 
tions must  be  subjected  to  plastic 
operations. 
Eczema. —  The  superficial  inflammations  of  the  skin  grouped  under 
the  general  head  of  eczema  possess  considerable  surgical  importance. 
When   compulsory  operative  measures  of  relief  are  imdertaken  in 
areas  of  eczema,  primary  union  is  not  likely  to  occur.    Eczema  may  be 

955 


Fig.    465. —  Cutaneous    Syndactylism. 
Fingers  enclosed  in  a  common  sheath 
of  skin. 


956     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


due  to  the  use  of  iodoform  tamponade  or  to  the  irritating  effect  of 
wound  secretion,  especially  in  cases  of  bone  disease  of  long  standing. 
It  often  occurs  upon  the  ha^ids  and  forearms  of  surgeons  and  is  ascrib- 
able  to  the  irritation  of  chemical  disinfectants.  It  is  impossible  even 
relatively  to  sterilize  surfaces  of  this  sort,  and  the  presence  of  the 
eruption  condemns  the  surgeon  to  inactivity. 

The  causation  of  eczema  is  local  and  constitutional.  The  local 
causes  are  friction  of  ap- 
posed surfaces  (intertrigo 
or  chafing  of  the  scrotum 
and  thigh,  the  groin,  the 
axilla,  and  beneath  the 
breasts)  or  by  scratching 
the  scabies,  prurigo,  urti- 
caria, insect  bites,  chemi- 
cal irritants,  and  thei'mal 
changes  produced  by 
radiating  heat  or  dry 
cold.  The  existence  of 
constitutional  causes  is 
borne  out  by  the  s^^mpto- 
matic  eczema  attendant 
upon  certain  diseases, 
such  as  icterus,  diabetes, 
nephritis,  chlorosis,  and 
dysmenorrhea. 

The  character  of  the 
disturbances  attendant 
upon  eczema  connotes 
many  forms  which  merge 
into  one  another.  It 
usually  begins  with 
severe  itching  and  red- 
ness (erythema),  which  is  soon  followed  by  the  appearance  of 
minute  vesicles  (eczema  vesiculosum)  or  pustules  (eczema  pustu- 
losum).  When  local  irritation  is  prolonged  the  macerated  epi- 
dermis is  thrown  off  {wet  eczema,  eczema  madidans),  leaving  an 
exposed  raw  surface,  which  soon  forms  crusts  and,  when  purulent 
infection  supervenes,  is  attended  with  considerable  loss  of  substance, 
the  entire  process  now  taking  on  the  form  of  an  impetigo.    Ultimately, 


Fig.  466. —  Cutaneous  Syndactylism. 
Fingers  connected  by  layer  of  skin. 


SURGICAL  DISEASES   OF  THE   SKIN  957 

the  process  takes  ou  the  dry  form  {eczema  squamosa)  and,  when  this 
exfoliates,  restitution  to  the  normal  occurs.  On  the  fingers  vesicular 
and  pustular  eczema  are  likely  to  be  attended  with  the  formation  of 
deep  rhagades,  which  are  maintained  in  a  state  of  constant  irritation 
by  the  activities  of  the  part. 

Acute  eczema  merges  into  the  chronic  form  when  the  cause  is  not 
promptly  dealt  with.  In  these  cases  the  skin  becomes  greatly  thick- 
ened as  the  result  of  infiltration.  Areas  of  chronic  eczema  present  a 
condition  of  affairs  favorable  to  the  development  of  skin  carcinoma 
(see  carcinoma  of  the  skin). 

The  locations  most  frequently  attacked  by  eczema  are  the  skin  of 
the  face,  the  head,  and  the  neck,  the  hands  and  the  feet,  the  genital 
organs,  and  the  axillae.  It  is  more  common  in  corpulent  persons. 
As  a  rule,  the  affliction  occurs  in  poorly  nourished  sections  of  the 
body,  such  as  the  skin  of  paralyzed  parts,  the  skin  over  tumors,  and 
in  cases  of  chronic  edema  and  elephantiasis. 

The  treatment  is  primarily  directed  toward  removal  of  the  cause. 
In  addition  to  this  the  eczematous  skin  should  be  protected  from  all 
irritating  influences,  of  which  rubbing  and  scratching  are  the  most 
important.  The  inflamed  surface  must  be  thickly  covered  with 
horic  or  zinc  salve,  held  in  place  with  a  layer  of  lint,  and  upon  this 
an  abundant  protective  dressing  applied.  The  dry  form  of  eczema 
is  best  treated  by  the  use  of  tar  preparations. 

The  eczema  of  the  surgeon's  hands  is  readily  amenable  to  the 
liberal  application  of  ten  per  cent  zinc  vaselin,  over  which  gloves  may 
be  worn.  Reasonable  care  in  cleansing  the  hands  will  prevent  its 
occurrence  (see  cleansing  of  the  hands,  p.  82). 

Edema  of  the  Skin  and  Mucous  Membranes. —  Ordinarily,  the  fluids 
contained  in  the  tissue  spaces  are  absorbed  through  the  walls  of  the 
capillaries  and  taken  up  by  the  circulation.  When  this  process  is 
disturbed  the  fluid  accumulates  in  the  tissues  or  in  the  cavities  of  the 
hody.  In  the  latter  situations,  the  accumulation  of  fluid  is  called 
hydrops  articularis,  hydrothorax,  hydropericardium,  and  ascites. 
"When  fluid  collects  in  the  vital  organs,  the  sliin  or  mucous  memhranes, 
the  term  edema  is  used ;  extensive  fluid  saturation  is  designated  as 
anasarca. 

The  most  important  causes  of  edema  are  venous  and  capillary  stasis 
and  disturbances  of  the  capillary  secretion;  edema  from  lymphatic 
stasis  is  less  frequent. 

Ven&us  stasis  is  attended  with  increased  pressure  in  the  capillaries 


958     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

and  an  overproduction  of  lymph.  When  the  stasis  is  prolonged,  nu- 
tritive changes  occur  which  relax  the  tissue  so  that  the  flow  of  lymph 
is  lessened,  though  the  capillary  walls  are  not  actually  more  permeable. 

Occlusion  of  the  large  veins  of  the  trunk  and  of  the  extremities  re- 
sults in  edema.  Ligature  of  the  main  vein  of  a  limb  is  usually  fol- 
lowed by  transitory  edema,  while  it  is  likely  to  be  rather  more  perma- 
nent when  obstruction  to  venous  return  is  due  to  thromhosis  or  to 
pressure  from  malignant  tumors,  both  of  which  not  infrequently 
occlude  collateral  vessels.  The  edema  due  to  prolonged  immobiliza- 
tion of  a  limb  (after  fracture)  is  due  to  feebleness  of  the  venous  cir- 
culation, a  fact  which  argues  against  unnecessarily  protracted  con- 
finement in  apparatus  in  this  class  of  cases. 

Disturbances  of  capillary  circulation  are  responsible  for  a  number 
of  forms  of  edema  and  are  the  result  of  interference  with  the  nutri- 
tion of  the  capillary  endothelium,  due  to  toxic,  chemical,  and  traumatic 
influences.  Damaged  capillary  walls  occupy  the  position  of  an 
easily  permeated  filter,  through  which  fluids  transude  in  proportion 
to  the  reduction  of  tension  the  causative  factor  produces,  or  in  accord 
with  the  increase  in  blood  pressure  consequent  to  inflammatory  hyper- 
emia (Landerer-). 

Inflammatory  edema  appears  in  the  skin  and  mucous  membranes  as 
a  part  of  the  phenomena  attendant  upon  inflammatory  processes  of 
bacterial,  toxic,  chemical  and  traumatic  origin,  or  it  may  follow  pro- 
longed ischemic  disturbances  such  as  occur  in  connection  with  tight 
bandaging. 

Hydremic,  cachectic,  or  marantic  edema  is  coincident  to  diseases 
that  lessen  the  protein  (anemia  and  cachexia  due  to  chronic  inflam- 
matory processes  or  malignant  disease)  or  those  that  increase  the 
watery  content  of  the  blood  (nephritis,  cardiovascular  insufficiency). 

Myxedema  is  due  to  chemical  changes  resulting  from  lessening  of 
thyroid  secretion  and  involves  the  face  and  the  extremities.  It  is 
characterized  by  the  presence  of  mucin  in  the  fluid  exudate  and  a 
peculiar,  tence,  doughy  distention  of  the  skin.  Myxedema  is  favor- 
ably influenced  by  the  persistent  administration  of  thyroid  extract  or 
by  transplantation  of  human  thyroid  gland  tissue. 

Edema  from  lymph  stasis  is  caused  by  occlusion  of  the  main  lym- 
phatic vessels  of  the  limb  and  of  the  thoracic  duct.  The  latter  is  often 
the  result  of  pressure  from  a  malignant  tumor;  the  former  occurs  in 
the  scrotum  and  lower  limbs  after  extensive  resection  of  the  inguinal 


SURGICAL  DISEASES  OF  THE   SKIN  959 

glands,  especially  when  collateral  circulation  is  abolished  by  chronic 
inflammatory  processes. 

Edema  ex  vacuo  is  a  term  applied  to  collections  of  fluid  in  situations 
where  portions  of  the  brain  and  cord  have  been  destroyed  b}'  patho- 
logical processes,  leaving  a  rigid  wall  isolated  from  the  circulation; 
it  also  occurs  in  hernial  sacs,  the  necks  of  which  are  occluded. 

Edema  of  the  Skin. — Edema  of  the  skin  is  always  attended  with 
more  or  less  infiltration  of  the  suhciitaneous  tissue,  as  the  latter  is 
capable  of  taking  up  a  large  quantity  of  fluid  and  at  times  the  intra- 
muscular tissue  is  also  invaded.  An  edematous  area  is  characterized* 
by  swelling  which  gradually  merges  into  the  surrounding  tissue,  is 
cool  and  waxlike  in  appearance  and,  w^hen  due  to  venous  stasis,  is 
bluish  in  color.  Afifected  limbs  lose  their  normal  contour,  are  heavy, 
and  easily  fatigued;  motion  is  restricted.  On  section,  clear  fluid 
oozes  from  the  divided  tissues. 

The  development  of  edema  is  always  gradual  and  its  infiltration 
disappears  when  its  cause  is  removed.  Chronic  edema  leads  to  trophic 
changes  in  the  skin,  which  becomes  rough  and  cracked,  and  has  a 
tendency  to  develop  eczema  and  other  inflammatory  processes.  When 
edema  persists  beneath  the  skin,  the  proliferation  of  connective  tissue 
produces  a  condition  of  pachydermia. 

The  fact  that  pressure  causes  transitory  pitting  in  an  edematous 
area  differentiates  it  from  elephantiasis,  diffuse  lipoma,  and  lymphan- 
gioma. 

The  treatment  of  edema  is  directed  toward  removal  of  the  cause,  the 
emplo}Tnent  of  measures  to  improve  the  circulation  hy  elevation  of 
the  part,  and  the  use  of  elastic  pressure.  "When  the  heart  is  enfeebled 
it  should  be  stimulated.  In  chronic  edema  the  improvement  of  the 
circulation  is  no  longer  possible.  In  all  cases,  other  than  those  due 
to  bacterial  thrombosis,  massage  and  hydrotherapy  are  useful  meas- 
ures. 

Edema  of  Mucous  Membranes. — Edema  of  mucous  membranes  is  due 
to  the  various  inflammatory  processes  or  to  interference  with  the 
circulation.  Acute  edema,  due  to  active  inflammation  or  to  sudden 
circulatory  stasis,  gives  rise  to  severe  edematous  saturation  of  the 
mucosa  and  submucosa  attended  with  great  swelling  which,  especially 
in  the  upper  air  pas.sages,  causes  grave  disturbances.  Edema  of  the 
nasal  mucosa,  which  interferes  with  breathing,  and  that  of  the  uvula 
are  common  phenomena.  Edema  of  the  larynx,  occurring  with 
catarrhal  and  diphtheritic  inflammatory  processes,  phlegmons,  and 


960    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

abscesses,  and  inflammatory  processes  in  the  vicinity  of  the  larynx, 
and  that  following  operations  in  the  neck,  is  likely  to  be  attended 
with  grave  menace  to  life.  Similar  causative  factors  produce  edema 
in  the  connective  tissue  of  the  eyelids  and  the  iulh  after  operations 
executed  in  the  region  of  the  eye. 

Chronic  edema,  due  to  venous  stasis  (in  cardiac  failure  and  pulmo- 
nary emphysema)  or  to  displacement  of  and  pressure  upon  the  main 
vein  of  a  mucous  membrane  zone,  is  less  menacing  than  that  caused 
by  chronic  inflammatory  processes.  The  latter  is  attended  with  hyper- 
plasia in  the  nose  and  the  accessory  sinuses,  which  form  so-called 
polypi  and  present  exceedingly  favorable  soil  for  the  development  of 
new  growths  such  as  papillomata,  fihromata,  adenomata,  and  carci- 
nomata.  It  is  probable  that  the  leukoplakia,  which  is  generally 
regarded  as  the  site  favorable  to  the  development  of  carcinoma  of  the 
lip,  cheek,  and  tongue,  is  due  to  chronic  irritation  (tobacco). 

Inflammatory  edema  of  mucous  memhrances  is  treated  in  the  same 

way  as   are   chronic    and    acute   inflammations    in    other   situations 

(p.  162).    Severe  edema  due  to  stasis,  when  accessible,  should  be  freely 

needled  or  incised.     Edema  glottidis  calls  for  immediate  tracheotomy. 

Elephantiasis. — Elephantiasis — in  contradistinction  to  elephantia- 
sis grecorum  or  lepra — known  also  as  elephantiasis  arabum  or  pachy- 
derma  acquisita,  is  an  acquired  thickening  of  the  skin  extending,  in 
severe  cases,  to  the  deeper  tissues  and  appearing  in  restricted  por- 
tions of  the  body.  As  a  rule,  the  enlargement  of  a  given  portion  of 
the  body  is  uniform  in  outline. 

The  underlying  pathogenesis  of  elephantiasis  is  twofold,  chronic 
inflammatory  hyperplasia  of  connective  tissue,  and  dilatation  of  the 
lymph  channels.  Its  causation  lies  in  prolonged  irritation  and  local 
(at  times  transitory)  circulatory  disturbances.  To  these  may  be  added 
thickening,  obliteration,  and  dilatation  of  the  veins  and  changes  in  the 
skin. 

The  development  of  elephantiasis  is  gradual,  extending  over  months 
and  years.  The  advent  of  the  condition  is  frequently  heralded  by  a 
chronic  inflammatory  edema,  which  owes  its  origin  to  lymph  stasis 
following  extirpation  of  infected  lymph  nodes,  or  it  is  the  outcome 
of  an  increased  formation  of  h^mph  coincident  to  dilatatimi  and 
thromhosis  of  veins.  Elephantiasis  of  the  scrotum  and  of  the  legs 
develops  in  this  way.  At  times,  recurring  acute  inflammatory  pro- 
cesses of  the  skin  and  subcutaneous  tissues,  especially  erysipelas, 
lymphangitis,  and  thrombophlebitis  are  responsible  for  the  condition, 


SURGICAL  DISEASES  OF  THE   SKIN 


961 


each  attack  contributing  to  the  progressive  thickening  of  the  skin. 
It  also  arises  in  connection  with  chronic  eczema,  tuberculous  and 
gummatous  ulcers,  or  fistulae  leading  to  dead  bone. 

Unna^  seems  to  have  shown  that  elephantiasis  may  foUow  strepto- 


FiG.    467. —  Elephantiasis    of    the    Left    Lowee 

EXTEEillTY   IN    A    WOilAN   FiFTT   YEARS    OP   AGE. 

The  skin  is  covered  •with  thick  crusts  and  is  tra- 
versed by  hard,  tumor-like  masses. 

coccie  inflammations  which  are  succeeded  by  residual  irritation  of  the 
connective  tissue.  This  particular  form,  following  inflammatory 
processes,  is  usually  restricted  to  a  single  lower  extremity,  the'  female 
genitals,  the  penis,  the  scrotum,  and  the  face  (lips  and  eyelids). 


962     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

The  thickening  of  the  skin  may  be  symmetrical,  but  not  infrequently 
is  arranged  in  flaps  of  various  forms  ^vhiell,  at  times,  resemble  pedicu- 
lated  fibromata.  The  skin  is  firmly  adherent  to  the  underlying  tissues 
and  cannot  be  raised  up  in  folds.  It  is  covered  with  pigmented  areas 
and  layers  of  horny  deposits;  in  some  places  (especially  the  scrotum) 
dilatation  of  superficial  lymph  vessels  forms  small  vesicles  which  dis- 


FiG.  468. —  Elephantiasis  Scroti. 


charge  lymph  {lymphorrhea) .  This  secretion  forms  crusts  consisting 
of  dried  secretions,  which  mingle  with  the  exudate  from  eczematous 
patches,  rhagades,  and  ulcers.  Papillomatous  proliferations  spring  up 
from  the  hyperplastic  connective  tissue,  presenting  a  clinical  picture, 
varied  by  recurring  attacks  of  acute  inflammatory  processes,  includ- 


SURGICAL  DISEASES  OF  THE   SKIN  963 

ing  lymphangitis,  l^Tnphangitic  phlegmon,  erysipelas,  and  lymphade- 
nitis. Gradually  connective  tissue  proliferation  extends  to  the  muscle 
fibers  (which,  in  the  meantime,  have  become  atrophic)  and  converts 
the  soft  parts  of  the  entire  limb  into  either  a  dense  indurated  or  a  soft 
gelatin-like  mass  (elepha)itiasis  dura  or  molle)  traversed  by  widely 
dilated  lymph  spaces  {elephantiasis  lijmphangiectatica) .  At  times 
the  periosteum  also  becomes  thickened. 

Elephantiasis  is  endemic  in  the  tropics  (Arabia,  India,  Central 
America,  etc.).  This  form  of  the  disease  is  insidious  in  onset,  but  is 
characterized  by  acute  exacerbations  attended  with  fever.  It  attacks 
one  or  both  lower  extremities  and  the  penis  and,  at  times,  the  arms, 
female  genitals,  head,  and  the  mammae;  its  course,  like  that  of  the 
sporadic  form,  may  be  rapid  or  gradual.  The  scrotum  is  especially 
liable  to  ma.ssive  enlargement,  so  that  the  site  of  the  penis  appears 
as  a  small  slit  in  the  enormous  hypertrophied  pendulous  mass  (Fig. 
468).  Lymphangitis,  lymphangitic  phlegmon,  and  lymphadenitis  are 
common  complications. 

The  endemic  form  of  elephantiasis  is  attributed  to  infection  wnth 
the  filaria  sanguinis  honiinis  or  other  filariae  (zur  Verth'*).  The 
embrj^os  (adult  male,  83  mm.  long,  adult  female,  155  mm.  long)  of 
the  worm  are  probably  taken  up  from  an  infected  person  hy  mos- 
quitoes and  transferred,  by  means  of  bites,  to  the  lymph  vessels  of 
others  where  they  develop  into  worms.  The  migrations  of  the  para- 
site cause  elongated  swellings  from  which  its  removal  may  be  accom- 
plished through  an  incision  after  arresting  its  progress  by  applying 
collodion  to  the  skin  or  by  blocking  the  lymph  vessels  with  salt  solu- 
tion infiltration.  The  presence  of  the  parasite  causes  Ij'mphatic 
obstruction  and  inflammation  which  ultimately'  result  in  elephantiasis. 
The  dissemination  of  the  embryos  by  the  blood  causes  hematuria  when 
the  kidneys  are  invaded,  and  chylous  diarrhea  occurs  when  the  thoracic 
duct  is  obstructed.  Zur  Verth*  seems  to  have  shown  that  the  infection 
is  attended  with  an  increase  of  eosinophils  (from  2-4  to  50  per  cent), 
a  factor  of  diagnostic  value. 

Acquired  elephantiasis,  or  pachyderma,  must  be  differentiated  from 
the  congenital  elephantiatic  forms  of  lymphangioma  and  neurofibroma 
(see  Tumors)  in  which  the  history  of  the  case  is  the  determining  factor. 
Regional  giant  formation  is  attended  with  enlargement  of  the  bone  and 
may  thus  be  differentiated  from  the  disease  under  consideration. 

Congenital  thickening  of  the  skin  and  subcutaneous  tissues  occurs  in 


964    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

certain  portions  of  the  extremities  and  is  due  to  contraction  by  amniotic 
bands.     This  also  is  not  attended  with  enlargement  of  the  bone. 

The  treatment  of  the  tumor-like  circumscribed  areas  consists  of 
excision.  The  complete  ablation  of  the  enlarged  scrotum  and  penis 
and  excision  of  the  elliptical  areas  are  followed  by  good  results. 
Elephantiasis  of  an  entire  limb  presents  a  difficult  problem. 

Ligature  of  the  main  artery  of  a  limb,  such  as  the  femoral  or  external 
iliac,  in  cases  of  elephantiasis  of  the  lower  extremity,  has  not  afforded 
permanent  relief.  Measures  of  relief  should  be  directed  toward 
enhancing  the  flow  of  Igmph  irrespective  of  the  cause  of  the  stasis. 
The  beneficial  effect  of  posture,  massage,  and  equable  pressure  is  only 
temporar}'.     Apparently  permanent  relief  follows. the  increased  drain- 


FlG.   469, KONDOLEON    OPERATION. 

The  aponeurosis  has  been  incised,  separated  from  the  muscle,  and  sutured  in 
such  a  way  as  to  allow  the  subcutaneous  fat  to  drop  on  the  muscles  after  the 
wound  is  closed.  A  portion  of  the  subcutaneous  fat  has  been  removed  (Sistrunk 
in  Surgery,  Gynecology  and  '  Obstetrics). 

age  of  lymph  following  Handley's  operation.^  This  consists  of  the 
introduction,  beneath  the  skin,  of  several  silk  threads  which  are  allowed 
to  heal  in  situ  and  establish  capillary  thread  drainage.  Lexer^  intro- 
duced six  silk  strands,  which  he  placed  beneath  the  skin  from  the 
properitoneal  tissue  to  the  dorsum  of  the  foot,  employing  numerous 
incisions  for  the  purpose  of  advancing  the  threads. 

The  Kondoleon  operation,'^  accurately  depicted  by  Sistrunk,^  seems 
to  have  given  brilliant  results.  Long  incisions  are  mads  along  the 
inner  and  outer  aspects  of  the  affected  limbs  and  through  each  of  these 
a  large  slice  of  edematous  fat  is  removed.  The  aponeurosis  is  then 
opened  and  a  portion  of  it,  three  or  four  fingers  in  width,  is  excised. 
The  M'ounds  are  closed  without  drainage  in  such  a  way  that  the  skin, 


SURGICAL  DISEASES  OF  THE   SKIN 


965 


with  the  fat  attached  to  it,  comes  in  contact  with  the  exposed  muscle 
(Fig.  469).  Localized  pendulous  Haps  may  be  excised  (Drandt^). 
Incidental  phlegmonous  inflammation  may  demand  amputation. 

Rhinophyma. —  Rhinophyma  is  a  special  form  of  elephantiasis 
sequential  to  prolonged  a^ne  rosacea  involving  chiefly  the  nose.  It 
occurs  in  elderly  persons,  especially  in  alcoholics.  A  severe  form  of 
the  affliction  is  shown  in  Fig.  470.  As  a  rule  the  region  contiguous  to 
the  nose  is  covered  with  red  spots  or  presents  soft  nodules,  while  the 
nose  itself  exhibits  deep  red  tumor-like  protuberances  and  flaps  which 
consist  of  connective  tissue  hyperplasia,  dilated  Mood  vessels  and 
hypertrophy  or  cystic  degeneration  of  the  sehaceous   hlands.     The 

histological  changes  are  simi- 
lar to  those  of  elephantiasis. 
The  surrounding  skin  usually 
is  studded  with  dilated  or  sup- 
purating follicles  and  large 
pores,  giving  it  a  spongy  ap- 
pearance. In  some  cases,  the 
cartilage  is  also  hyper- 
trophied.  As  to  the  primary 
tissue  changes,  there  is  con- 
siderable difference  of  opin- 
ion. Von  Hebra^"  taught  that 
the  process  was  essentially 
one  of  connective  tissue 
hyperplasia;  Lassar^^  consid- 
ered degeneration  of  the 
sebaceous  glands  as  the  causa- 
tive factor.  Lesser^^  believes 
the  disease  to  be  primarily  a  dilatation  of  the  blood  vessels  of  nervous 
origin.  Y.  Bruns^^  submits  some  evidence  of  an  hereditary  influence. 
The  operative  treatment  of  the  hypertrophied  areas  by  excision  with 
the  knife  or  thermocautery  results  in  great  improvement  from  a 
cosmetic  standpoint.  Fritze  and  Reich^*  report  an  excellent  result 
following  a  wedge  shaped  excision  carried  out  by  Dieffenbach.  When 
removal  of  the  process  leaves  extensive  defects,  the  area  may  be  cov- 
ered b}'  suitably  shaped  flaps  or  hy  skin  grafting.  In  this  connection, 
J.  D.  Bryant^^  presents  a  case  w^hich,  because  of  its  magnitude  and 
favorable  outcome,  is  fraught  with  great  interest.  On  the  other  hand, 
it  is  worth  remembering  that  defects  of  considerable  size  will  heal 


966     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

spontaneously  as  a  result  of  reparative  proliferation  from  residual 
sebaceous  glands  in  the  same  way  as  obtains  in  connection  with  burns. 

BIBLIOGRAPHY 

1.  Bausch.     Zeitsehr.  f.  Heilk.  Bd.  12,  1891,  with  lit. 

2.  Landerer.     Gewebssi^amiung,  Leipzig,  1884. 

3.  Unna.     Histopatb.  d.  Hautkrank.,  Berlin,  1894. 

4.  ZUR  Verth.     Deutseh.  med.  Woch.,  1908. 

5.  Handlet.     Lancet,  1908,  i. 

6.  Lexer.     Allg.  Chir.,  Stuttgart,  1914. 

7.  KoNDOLEON.     Miinch.  med.  Woch.,  1912. 

8.  SiSTRUNK.     Surg.  Gyn.  Obst.  xxvi,  1918. 

9.  Brandt.     Arch.  f.  Derm.  u.  Syph.,  Bd.  100,  1910. 

10.  V.  Hebra.     See  No.  12. 

11.  Lassar.     See  No.  12. 

12.  Lesser.     Lehrbuch.  d.  Hautkrankheiten,  Leipzig. 

13.  V.  Bruns.     Beitr.  z.  klin.  Chir.,  Bd.  39,  1903. 

14.  Fritze  and  Reich.     Plastic  Chir.,  Berlin,  1845. 

15.  J.  D.  Bryant.     Op.  Surg,  i,  D.  Appleton  &  Co.,  New  York  and  London, 

1905. 


CHAPTER  II 
DISEASES  OF   MUSCLES  AXD   TENDONS 

Congenital  Muscular  Defects. —  Congenital  defects,  consisting  of 
atypical  insertion  and  complete  absence  of  groups  of  muscles,  interfere 
with  function  and  must  be  differentiated  from  paralysis.  The  co- 
existence of  other  deformities,  such  as  syndactylism,  polydactylism 
and  bone  defects,  usually  establish  the  diagnosis.  Congenital  absence 
of  the  trapezius  muscles  has  been  found  to  be  responsible  for  the 
abnormal  elevation  of  the  scapula,  so  frequently  observed. 

Atrophy  of  Muscles. —  Muscular  atrophy  may  be  simple  or  degenera- 
tive in  character.  The  former  consists  of  .shortening,  thinning,  and 
lessening  in  quantity  of  muscle  fibers.  In  its  degenerative  form,  the 
muscle  fibers  undergo  actual  pathological  changes,  such  as  fatty  degen- 
eration, coagulation  or  liquefaction.  In  the  last  instance,  the  muscle 
fibers  are  replaced  by  proliferation  of  connective  or  fatty  tissue. 

Simple  atrophy  occurs  most  frequently  after  nonuse  {disuse 
atrophy)  of  a  muscle  or  group  of  muscles,  after  cerebral  paralysis, 
and  in  connection  with  diseases  of  joints  {reflex  atrophy).  In  simple 
atrophy,  the  electrical  excitability  of  a  muscle  is  lessened  but  the 
reaction  of  degeneration  is  not  present. 

Simple  muscular  atrophy  results  in  decrease  in  the  size  of  the 
muscle,  complete  or  incomplete  loss  of  function,  and  in  contracture 
from  .shortening  of  antagonistic  muscles. 

Disuse  and  reflex  atrophies  are  not  readily  distinguished  from  each 
other.  Diminution  in  bulk  of  unused  or  immobilized  limbs  is  com- 
monly observed.  In  cases  of  injury  to  or  disease  of  bones  coyitiguous 
to  joints,  and  in  dislocations  or  inflammation  of  joints,  atrophy  occurs 
in  from  one  to  two  weeks  and  is  especially  marked  in  the  extensor 
groups  of  muscles  (deltoid,  triceps,  quadriceps,  and  gluteales). 
Muscles  that  cross  a  single  joint  atrophy  most  rapidly  (Jansen^). 

So-called  arthritic  muscle  atrophy  does  not  seem  to  be  explainable 
on  the  ground  of  disuse  alone,  as  the  atrophy  occurs  too  rapidly,  is 
present  when  immobilization  apparatus  is  not  employed,  and  does  not 

967 


968    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

appear  to  a  commensurate  degree  in  cases  of  hemiplegia  (Hoffa-). 
From  this  viewpoint  many  observers  (Paget,  Vulpian,  Charcot,  etc., 
quoted  by  Flautau^)  explain  the  atrophy  on  the  basis  of  the  reflex 
theory,  according  to  which  the  local  pathological  process  acts  through 
the  sensory  nerves  upon  the  spinal  cord,  where  the  irritation  produces 
a  damaging  effect  upon  centers  in  the  anterior  horns  of  gray  matter, 
affecting  mostly  the  areas  dominating  the  extensor  muscles.  Experi- 
mentally produced  arthritis  of  the  knee  is  not  attended  with  atrophy 
when  the  posterior  roots  of  the  sacral  plexus  are  divided  (Hoffa-). 

Degenerative  atrophy  follows  severe  injuries,  inflammation,  and  cir- 
culatory disturhances  caused  by  tumors  or  infectious  diseases  (espe- 
cially typhoid  fever  and  tetanus,  more  rarely  in  general  p3'ogenic 
infections)  ;  it  also  occurs  in  cases  of  peripheral  paralysis  due  to 
nerve  injuries  and  nerve  degenerations  and  pathological  processes  in 
the  anterior  horns  of  gray  matter  in  the  spinal  cord. 


Fig.  471. —  Ischemic  Muscle  Contracttjre  'Following  Improper  Application  op 
A  Gypsum  Dressing;  Deep  Ulceration. 

Degenerated  muscles  have  a  tendency  to  shrink  and  shorten,  which 
leads  to  great  functional  disturbances  and  contractures. 

Grave  circulatory  disturbances  result  from  complete  obstruction  to 
the  arterial  circulation,  a  condition  of  affairs  that  follows  injuries, 
ligature,  emholism  and  thrombosis  of  a  large  artery  where  there  is  no 
collateral  circulation ;  it  also  follows  compression  of  an  artery  by 
hone  fragments  (bend  of  the  elbow),  by  large  hematomata  (Groves*), 
by  prolonged  action  of  extreme  cold,  by  improperly  applied  g3T)Sum 
dressings  (Fig.  471),  and  when  the  v.  Esmarch  constriction  has  been 
left  in  place  for  more  than  three  hours. 

The  process  is  attended  with  severe  pain  and  extensive  inflammatory 
swelling;  the  muscles  are  hoard-like  and  fixed;  passive  motion  is 
painful, 


DISEASES  OF  MUSCLES  AND  TENDONS  969 

Immediate  release  of  pressure  by  liberal  incision  of  the  fascia  is,  at 
times,  followed  by  return  to  the  normal  (Bardenheuer'^)  ;  however, 
ordinarily  the  muscles  undergo  contracture  (due  to  cicatricial  con- 
traction) which  is  progressive  in  character.  These  contractures  take 
on  severe  forms  when  an  entire  group  of  muscles  (such  as  occurs 
when  the  flexors  in  the  forearm  degenerate  as  the  result  of  gj-psum 
dressing  pressure)  is  wholly  degenerated,  although  function  returns 
if  a  portion  of  the  muscle  fibers  is  preserved.  In  a  certain  number  of 
instances  deep  ulceration  occurs  (Fig.  471).  Lesser*^  credits  v.  Volk- 
man  with  first  describing  this  condition,  which  the  latter  characterized 
as  ischemic  muscle  paralysis  and  contracture.  The  general  belief  that 
muscles  of  this  sort  are  not  attended  with  nerve  degeneration  is  com- 
bated by  Hildebrand,^  who  calls  attention  to  the  fact  that  sensory 
disturbances  follow  nerve  degenerations  that  are  consequent  to  the 
pressure  caused  by  the  shrinkage  of  ischemic  muscles. 

Neurological  is  differentiated  from  ischemic  muscle  paralysis  by  the 
absence  of  response  to  electrical  excitation. 

The  clinical  course  of  muscle  atrophy  depends  upon  its  cause  and 
degree.  AYlien  the  cause  is  removed,  and  the  degenerative  process  is 
not  too  far  advanced,  recovery  is  materially  assisted  by  massage, 
mechanotherapy,  and  iaths,  and,  in  cases  of  neurogenous  paralysis, 
by  electricity.  In  severe  cases,  contractures  varying  in  degree  remain ; 
these  demand  special  treatment  (Part  VIII).  In  cases  of  ischemic 
paralysis,  Hildebrand^  suggests  early  transplantation  of  the  nerve  to 
a  point  immediately  beneath  the  fascia. 

Thickening,  Ganglion,  and  Ossification  of  Tendons. —  Small  nodules  or 
spindle  shaped  enlargements  appear  upon  the  tendons  of  flexor  muscles 
and  are  responsible  for  so-called  trigger  fingers.  The  mechanism  of 
this  manifestation  is  as  follows :  during  the  to  and  fro  movements  of 
the  tendon  its  thickened  area  is  arrested  by  a  band  of  its  sheath,  the 
resistance  of  which  is  overcome  by  either  active  or  passive  (help  of 
the  other  hand)  motion,  causing  the  finger  suddenly  to  complete  its 
movement  as  the  nodule  .slips  under  the  obstructing  band.  At  times 
the  thickened  portion  of  the  tendon  may  be  followed  by  the  palpating 
finger  as  it  is  intermittently  arrested  and  released  as  the  muscle 
functionates. 

Exposure  of  the  tendon  for  the  purpose  of  excising  the  nodule  dis- 
closes a  restricted  fibrous  proliferation,  which  usually  contains  a  round 
kernel  or  may  be  dilated  to  form  a  cyst  (ganglion)   (Lexer^). 

The  hyperplasia  of  fibrous  tissue  no  doubt  is  a  sequel  of  minute 


970    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

hemorrhages  that  occur  within  the  substance  of  the  tendon  following 
trauma.  Transient  thickening  of  several  tendons  in  the  hand  fre- 
quently occurs  in  connection  with  prolonged  mechanical  irritation, 
such  as  rowing,  etc.  It  is  often  seen  in  recruits  during  early  experi- 
ences in  carrjdng  a  rifle. 

Degenerative  cysts  of  tendons,  also  called  ganglia,  resemble  those 
seen  in  the  capsules  of  joints  and  probably  are  also  traumatic  in  origin. 
This  form  of  cyst  is  found  in  the  tendons  of  muscles  other  than  those 
of  the  hand,  such  as  the  peroneus  tertius,  triceps,  and  ligamentum 
patellae  (Bergemann^°). 

Ossification  of  tendons  is  often  seen  in  old  birds.  In  the  human, 
it  usually  occurs  in  connection  with  myositis  ossificans.  However, 
Hornung^^  reports  a  case  of  primary  tendinitis  ossificans  involving 
both  Achilles  tendons  following  trauma.  Frangenheim^-  reports  one  of 
Lexer's  in  which  the  tendon  of  the  triceps  was  ossified.  Densow^^ 
tells  of  meeting  with  the  condition  in  the  quadriceps  and  Achilles 
tendons  in  the  same  case. 

BIBLIOGRAPHY 

1.  JANSEN.     Arch.  f.  klin.  Chir.,  Bd.  96,  1912. 

2.  HOFPA.     Chir.  kong.  Verh.,  1892,  i. 

3.  Flautau.     Zentrbl.  a.  d.  Grenzgeb.,  1902,  No.  8. 

4.  Groves.    Brit.  Med.  Jr.,  1907. 

5.  Bardenheuer.     Deutseh.  Zeitschr.  f.  Chir.,  Bd.  108,  1910. 

6.  Lesser.     Samml.  klin.  Vort.,  1884,  No.  249. 

7.  Hildebrand.     Samml.  klin.  Vort.,  190G,  No.  437. 

8.  Hildebrand.     Deutseh.  Zeitschr.  f.  Chir.,  Bd.  95,  1908. 

9.  Lexer.     Allg.  Chir.  ii,  Stuttgart,  1914. 

10.  Bergemann.     Beitr.  z.  klin.  Chir.,  Bd.  66,  1910,  with  lit. 

11.  HoRNUNG.     Miinch.  med.  Wor'h.,  1908. 

12.  Frangenheim.     Med.  Klinik,  1909. 

13.  Densow.     Konigsberg,  1910. 


CHAPTER  III 

DISEASES  OF  TENDON  SHEATHS  AND  BURSAS 

Synovitis. —  Dry  synovitis  {synovitis  sicca)  of  teudon  sheaths  follows 
great  exertions  and  occurs  in  connection  with  lacerations  of  tendons. 
The  term  tenalgia  crepitans  is  based  on  the  sensation  of  friction  or 
crepitation  elicited  by  palpation  w'hen  the  tendon  is  moved.  The 
roughening  of  the  tendon  is  due  to  the  formation  of  fibrinous  deposits 
sequential  to  serosanguineous  exudates  in  situations  where  the  tendons 
move  to  and  fro  as  the  part  functions.  The  lesion  is  attended  with 
severe  pain  on  motion,  and  the  formation  of  long  slender  areas  of 
swelling  due  to  inflammatory  infiltration  of  the  contiguous  tissues. 

Return  to  the  normal  occurs  rapidly  (from  three  days  to  two  weeks). 
However,  as  the  disease  is  most  often  occupational  in  origin,  relapses 
are  frequent. 

Recurrent  dry  tendosynovitis  occurs  on  the  extensor  side  of  the 
thumh  in  laundresses,  in  carpenters  who  work  much  with  boring  tools, 
in  hlacksmiths  and  locksmiths  from  prolonged  use  of  hammers,  in 
drummers,  and  in  piano  players.  The  tendons  of  the  peronei  and 
tibialis  anticus  are  often  affected  in  oarsmen  who  use  the  "sliding 
seat."  A  similar  lesion  occurs  in  the  tendo  Achillis  of  ballet  dancers, 
and  in  adults  with  congenital  dislocation  of  the  hip,  though  this  tendon 
has  no  sheath  but  is  surrounded  by  a  double  layer  of  connective  tissue 
(de  Bovis^).  In  this  situation  the  process  is  similar  to  that  occurring 
between  the  crural  fascia  and  the  fascia  propria  of  the  muscles  on  the 
extensor  side  of  the  leg  ("Weiss-).  V.  Frisch*  adduces  some  evidence 
that  the  process,  in  many  eases,  is  reall}''  a  peritendinitis  at  the  point 
where  the  muscle  becomes  tendinous. 

The  diagnosis  is  not  difficult ;  it  is  based  upon  the  site  and  form  of 
the  swelling,  substantiated  by  palpation  of  the  crepitation.  As  the 
latter  is  only  elicited  by  certain  motions,  confusion  with  regard  to 
joint  lesions  should  not  arise. 

The  treatment  consists  of  immo'bilizaHon  of  tlie  part  in  a  circular 
gj'psum  dressing  or  in  appropriately  fashioned  splints.     As  a  rule, 

971 


972     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

return  to  the  normal  occurs  in  a  few  days.  When  the  process  persists 
for  more  than  two  weeks  gentle  massage  is  of  benefit.  Exertion  should 
not  be  permitted  until  recovery  is  complete. 

Serous  and  serofibrinous  exudates  in  tendon  sheaths  often  follow 
effusion  of  blood  occurring  in  connection  with  fractures  and  disloca- 
tions. They  usually  disappear  while  the  more  serious  causative  lesion 
is  being  repaired. 

Chronic  hydrops  of  tendon  sheaths  is  usually  tuberculous  (p.  469). 

Chronic  changes  in  tendon  sheaths  following  trauma  or  prolonged 
exertion  are  not  common.  They  have  been  observed  in  connection 
with  dislocated  and  severely  lacerated  tendons  (Hildebrand^).  De 
Quervain^  describes  the  condition  under  the  name  of  stenosing  tendo- 
vaginitis occurring  in  the  wrist  joints. 

Ganglia  of  tendon  sheaths  are  uncommon.  They  present  a  histologi- 
cal picture  similar  to  that  occurring  in  joints,  but  are  smaller  and 
usually  are  situated  in  the  region  of  the  metacarpophalangeal  articu- 
lations at  the  lateral  aspect  of  the  flexor  tendons,  where  they  make 
pressure  on  the  digital  nerves,  causing  neuralgia  which  rapidly 
disappears  when  the  cyst  is  removed  (WitzeP). 

JJric  acid  is  deposited  in  tendon  sheaths,  but  it  usually  occurs  in 
connection  with  gouty  arthritis. 

Bursitis. —  Calcareous  deposits  are  not  infrequently  found  in  chroni- 
cally inflamed  bursae  of  the  shoulder  joint  (Bergemann  and  Stiede^). 

Hygroma  is  a  term  employed  to  designate  cystic  changes  in  bursae 
due  to  chronic  inflammatory  processes.  They  occur  sequentially  to 
the  incomplete  absorption  of  bloody  effusion,  or  are  the  result  of 
prolonged  mechanical  irritation. 

The  contents  of  a  h^'groma  is  at  first  mucoid,  later  serous,  and,  if 
preceded  by  a  contusion,  is  sanguineous  in  character.  The  cyst  wall 
is  smooth  when  the  process  is  acute,  but  soon  becomes  thickened  and 
covered  with  villous  and  warty  growths,  separated  by  deep  and  more 
or  less  roughened  irregular  cavities.  At  times,  villous  proliferation 
fills  the  greater  part  of  the  sac ;  in  other  instances,  the  cj^st  wall  is 
lined  wi'h  coagulated  blood.  Foreign  bodies  may  lodge  in  any  of  the 
burs8B  and  rj'ive  rise  to  inflammation. 

The  occurrence  of  hygroma  cannot  be  entirely  explained  on  the 
ground  of  a  causative  chronic  inflammatory  process,  though  no  doubt 
it  is  an  important  factor.  Even  recently  formed  hygromata  do  not 
always  consist  of'  simple  cysts,  but  are  very  often  multilocular 
(Schuchardt^)    or   contain   free  masses   of   contracted   fatty  tissue, 


DISEASES  OF  TENDON  SHEATPIS  AND  BURSAE      973 


derived  from  that  surrounding  the  bursas  (Graser^).  It  is  not  im- 
probable that  certain  changes  take  place  in  the  fatty  tissue  surround- 
ing a  bursa  and  in  its  proper  wall,  converting  it  into  colloid  material; 
this  is  soon  changed  into  a  fibin-like  intermediate  substance  which  in 
turn  undergoes  liquefaction  (Langenbeck^*').  In  this  way  the  wall  of 
the  bursa  and  the  tissue  in  its  vicinit}'  become  the  site  of  degeneration 
cysts,  which  rupture  into  the  bursal  cavity  and  cause  the  proliferative 

changes  already  de- 
scribed. This  concep- 
tion of  the  process 
places  it  in  the  class 
with  the  ganglia: 

In  many  instances 
the  eifusion  of  blood 
into  a  bursa  forms  a 
symmetrical,  globular 
protuberance  which  ap- 
pears gradually',  is  not 
attended  with  disturb- 
ances, and  is  covered 
with  smooth,  normal, 
or  more  or  less  thick- 
ened skin.  H^'gromata 
attain  the  size  of  a 
hen's  egg  or  larger,  but 
may  be  as  big  as  an 
apple.  Their  appar- 
ently sharply  defined 
edges  merge  with  the 
deeper  tissues,  where 
the  tumor  is  attached 
either  to  the  tendon 
sheath  or  the  surface 
of  the  bone,  and  for  this  reason  are  not  freely  movable.  Fluctuation 
is  usually  present  and,  when  distention  is  not  too  great,  the  nodular 
content  is  palpable,  giving  rise  to  a  sensation  of  crepitation. 

Deeply  located  hygromata  interfere  with  the  mobility  of  the  con- 
tiguous joint ;  the  superficial  have  a  tendency  to  rupture  and  to 
suppurate. 

The  diagnosis  of  hygoma  is  based  on  the  clinical  manifestations 


Pig.  472. —  Hygroma  Burs.e  Olecrani. 


974    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

stated,  together  with  the  location  of  the  process,  i.  e.,  in  portions  of  the 
body  where  bursa  are  normally  situated  and  are  suhjected  to  presuire 
by  hony  prominences.  The  olecranon  and  prepatellar  bursae  are  most 
frequently  affected  (housemaids,  scrubwomen,  miners,  etc.).  The 
bursEe  of  the  shoulder,  hip,  and'  popliteal  areas  are  invaded  next  in 
frequency  in  the  order  mentioned.  Vicarious  hurscB  are  formed  on 
the  outer  aspect  of  the  club  foot  and  attain  considerable  size.  The 
bursa  over  the  head  of  the  metatarsal  bone  often  develops  a  hygroma 
in  connection  with  hallux  valgus. 

As  a  rule  hj'groma  is  unilateral,  but  may  be  bilateral  when  the  causa- 
tive factor  is  operative  on  loth  sides  of  the  hody.  Deeply  located 
hygromata  near  the  hip  and  the  knee  may  be  confused  with  tumors  or 
with  gravitation  abscesses.     Aspiration  clears  up  the  diagnosis. 

The  treatment  depends  upon  the  condition  of  the  bursal  sac.  "When 
the  wall  of  the  e^'st  is  not  palpably-  thickened,  aspiration  followed  by 
pressure  and  the  injection  of  tincture  of  iodin  or  of  carbolic  acid  may 
result  in  obliteration  of  the  sac.  In  cases  in  which  the  bursal  sac  is 
much  thickened,  complete  excision  is  necessary.  The  latter  is  also 
indicated  when  the  cavity  of  the  bursa  communicates  with  a  discharg- 
ing fistula  following  spontaneous  rupture. 

BIBLIOGRAPHY 

1  DE  Bovis.     Semaine  med.,  1907. 

2.  Weiss.     Beitr.  z.  klin.  Cbir.  Bd.  54,  1907. 

3.  v.  Frisch.     Arch.  f.  klin.  Cbir.  Bd.  89,  1909. 

4.  HiLDEBKAND.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  86,  1907. 

5.  DE  QuERVAix.     Miinch.  med.  "Woch.,  1912. 

6.  WiTZEL.     Zentrbl.  f.  Chir.,  1888. 

7.  Bergemaxx  und  Stiede.     Miinch.  med.  "Woch.,  1908. 

8.  SCHUCHARDT.     Chir.  kong.  Verb.,  1890,  ii. 

9.  Graser.     Zentrbl.  f.  Chir.,  1913. 

10.     Langenbeck.     Arch.  f.  klin.  Chir.,  Bd.  70,  1903. 


CHAPTER  IV 
DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS 

Arteriosclerosis,  Atherosclerosis. —  Chronic  deforming  endarteritis,  or 
arteriosclerosis,  also  designated  as  atheroma  of  the  arteries,  stands  in 
a  causative  relationship  to  many  conditions  of  importance  to  the 
surgeon. 

This  chronic  process,  which  may  involve  certain  sectors  of  the 
arterial  system  or,  as  is  most  commonly  the  case,  affect  the  entire 
arterial  apparatus,  is  essentially  a  disease  of  later  life  (rarely  before 
forty)  and  is  degenerative  in  character  (Marchand^).  Fatty  degen- 
eration and  proliferation  of  the  intima  proceed  together,  and  are 
succeeded  by  areas  of  atheromatous  ulceration,  which  in  turn  undergo 
fibrous  contraction  and  calcification.  The  insular  form,  consisting  of 
small,  hard,  flat  areas  of  thickening  or  ulcerative  degeneration 
{arteriosclerosis  circumscripta  or  nodosa),  often  merges  into  that 
characterized  by  diffuse  proliferation  of  the  intima  {arteriosclerosis 
diffusa)  which  leads  to  obliteration  of  the  smaller  vessels  {endarteritis 
obliterans).  As  the  process  progresses,  the  media  is  also  invaded  by 
fibrous  changes  or  undergoes  calcification  which  (especially  in  the 
lower  limbs)  is  attended  with  the  formation  of  nodules.  '  The  cellular 
infiltration  and  thickening  of  the  adventitia  never  reaches  the  magni- 
tude common  to  luetic  proliferation. 

The  diseased  arteries  are  hard,  tortuous,  and  palpable  through  the 
skin ;  on  section,  their  lumen  is  manifestly  narrowed.  Their  rigidity 
renders  hemostatic  deligation  difficult.  When  exposed  by  incision  the 
vessels  appear  as  yellowish  white,  irregular,  nodular  strands.  They 
throw  a  faint,  beaded  shadow  on  the  X-ray  negative  when  calcification 
is  advanced. 

The  causation  of  atherosclerosis  is  a  much  confused  problem. 
Marehand^  submits  evidence  to  show  that  the  process  is  primarily 
nutritional  in  character  in  the  media,  and  is  followed  by  connective 
tissue  hj-perplasia  in  the  intima.  Not  a  few  authorities  regard  it  as 
inflammatory,  involving  all  the  coats.     Thoma*  considers  the  media  to 

975 


976     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

be  primarily  the  seat   of   degeneration,   followed  by   compensatory 
proliferation  of  the  intima. 

The  chief  predisposing  cause  would  seem  to  be  overexertion  on  the 
part  of  the  arteries  from  distention  of  the  lumen,  the  outcome  of  inter- 
mittent or  constant  increase  of  blood  pressure  (Marchand^).  To  this 
may  be  added  certain  general  and  local  conditions,  such  as  diseases  of 
the  central  nervous  srjsteni  and  of  peripheral  nerve  trunks  (tabes, 
syringomyelia,  neuritis),  the  action  of  toxic  suhsta7ices  (alcohol, 
tobacco,  ergot,  lead,  mercury,  phosphorus)  ;  infectious  diseases,  espe- 
cially the  chronic  ones,  such  as  lues  and  lepra ;  the  diatheses  (gout, 
diabetes)  ;  severe  prolonged  exertion;  thermal  influences  (prolonged 
action  of  a  moderate  degree  of  cold)  (v.  ManteuffeP). 

The  effects  of  arteriosclerosis  are  :  (1)  Disturbances  of  the  systemic 
circulation  and  consequent  interference  with  the  function  of  the  vari- 
ous organs,  which  results  from  the  lessened  distensibility  and  the 
narrowing  of  the  lumen  of  the  vessels.  The  circulatory  disturbances 
are  most  marked  when  the  veins  are  also  sclerotic.  (2)  Occlusion  of 
vessels  by  obliteration  and  thromljosis  or  by  an  embolus  derived  from 
a  centrally  located  area  of  atheromatous  ulceration.  When  this  hap- 
pens in  conjunction  wath  cardiac  insufficiency  and  diseased  collateral 
vessels,  local  gangrene  is  likely  to  occur  {senile  gangrene  of  the  fingers 
and  toes,  embolic  gangrene  of  an  entire  limb).  (3)  Rupture  of  a 
vessel,  which  occurs  most  frequentlj^  in  the  brain.  (4)  Aneurism. 
(5)  Thrombosis. 

Aneurisms. —  An  aneurism  may  be  defined  as  a  pathological  dilata- 
tion of  an  artery.  Aneurisms  are  divided  into  two  principal  forms, 
simple,  or  arterial,  and  arteriovenous.  The  former  consists  of  a 
dilatation  of  the  arterial  wall;  in  the  latter  communication  exists 
between  the  artery  and  the  vein,  with  or  without  an  intervening  sac 
(varix).  Pulsating  or  arterial  hematoma  is  also  included  under  the 
head  of  aneurism,  although  the  wall  of  the  sac  consists  of  the  tissues 
surrounding  the  effusion  of  blood  and  of  layers  of  fibrin  and  not  of 
the  wall  of  the  artery  itself.  On  these  varying  conditions  the  classi- 
fication of  false  and  true  aneurism  is  based. 

Classified  on  the  basis  of  the  form  that  aneurismal  dilatations  take, 
they  are  divided  into  diffuse  and  circumscribed.  The  term  sacculated 
(sacciform)  is  used  when  one  side  of  the  vessel  wall  bulges;  when  the 
widening  is  symmetrical,  it  is  called  cylindrical  (cylindricum)  ;  when 
tapering,  spindle  shaped  (fusiform)  ;  and  when  irregular,  the  term 
cirsoid  (angioma  racemosum)  is  employed, 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     977 

True  arterial  aneurisms  are  further  subdivided  in  accord  with  the 
provocative  factor: 

Congenital  aneurism  of  the  abdominal  aorta  has  been  reported  by 
Phanomenow/  Thoma^  reports  its  occurrence  in  connection  with 
the  ductus  Botalli.  Eppinger"  has  observed  multiple  aneurisms  of  the 
smaller  arteries,  which  he  ascribes  to  congenital  defects  in  the  elastic 
elements  of  the  vessels. 

Spontaneous  aneurism  occurs  in  two  forms:  (1)  Aneurism  ty  dis- 
tention (Thoma'),  in  which  the  diseased  vessel  wall  stretches  at  its 
weakest  point  (arteriosclerosis,  inflammation,  scar  tissue  following 
trauma).  (2)  Aneurism,  hy  rupture  (Eppinger"),  in  which  the  elastic 
elements  of  the  media,  together  with  the  healthy  or  diseased  vessel 
walls,  are  lacerated  as  the  result  of  a  sudden  increase  of  blood  pressure 
coincident  to  severe  bodily  exertion  or  to  psychic  influences.  The  dila- 
tation aneurism  appears  in  the  form  of  a  diffuse  widening  with  irregu- 
lar areas  of  sacculation  (diffuse  aneurism  or  arteriectasis)  and  may  be 
spindle  shaped  or  cylindrical  in  outline  (Fig.  473)  ;  the  aneurism  by 
rupture  is  usually  sacculated.  As  a  general  rule,  aneurisms  are  devel- 
oped in  situations  in  which  the  artery  is  surrounded  by  soft  parts,  i.  e., 
where  there  is  little  resistance  to  blood  pressure. 

'  Aneurism  T)y  erosion  occurs  in  an  artery  situated  in  a  zone  of  acute 
or  chronic  inflammation  (tuberculous  abscess)  ;  the  wall  of  the  vessel 
is  infiltrated  by  the  invading  process  and  becomes  necrotic  (arteritis 
purulenta,  p.  283),  and  may  undergo  aneurismal  deformation  pre- 
liminary^ to  rupture.  Under  these  circumstances  the  destruction  of 
the  outer  walls  of  the  vessels  is  at  times  followed  by  a  sacculated  pro- 
trusion of  the  intima  {hernial  aneurism) . 

Embolic  aneurism  follows  injury  of  the  intima  from  the  forceful 
impact  of  a  hard  embolus  derived  from  an  arteriosclerotic  or  calcified 
area  in  a  centrally  located  vessel,  and  occurs  frequently  in  the  brain. 
It  may  also  follow  an  infection  of  the  intima  sequential  to  the  deposit 
of  an  infective  embolus  (mycotic  aneurism) . 

True  traumatic  aneurism  consists  of  a  sacculated  protrusion  of  the 
wall  of  an  artery  following  trauma,  which  lacerates  or  crushes  the 
vessel. 

Dissecting  aneurism  is  the  result  of  tearing  or  disease  of  the  intima 
alone  or  together  with  the  media,  especially  in  connection  with  athero- 
matous ulcers  in  the  ascending  aorta  or  in  the  arteries  of  the  brain. 
The  blood  spreads  between  the  layers  of  the  vessel  (most  often  between 
the  media  and  the  intima),  forming  a  diffuse  cylindrical  aneurism, 


978     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


Fig.  473. —  A,  Fusiform  Aneurism  of  the  Popliteal  Artery  Developing  in  a 
Male  Patient  Fifty-nine  Years  of  Age.  B,  Longitudinal  Section  of  the 
Same  Preparation. 

The  thigh  was  amputated  above  the  knee  because  of  gangrene  of  the  foot. 
e,  Advanced  arteriosclerosis;  g,  small  saccular  evaginations  in  the  posterior  tibial 
artery.  /,  Thick,  laminated  thrombus  in  the  popliteal  aneurism.  The  thrombus 
extends  into  the  posterior  tibial  artery  (c)  down  to  the  origin  of  the  peroneal 
artery  (i),  the  lumen  of  which  is  greatly  narrowed.  The  posterior  (c)  and 
anterior  tibial  (a)  arteries  are  closed  by  thrombi.  The  peroneal  artery  (b)  is 
closed  by  endarteritis,      (d)  Calcified  plaque. 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     979 

although  the  process  may  be  restricted  to  sacculation.  The  blood  may 
coagulate  between  the  coats  of  the  vessel  or  may  rupture  through  the 
adventitia. 

A  false  traumatic  aneurism  develops  from  a  sacculated,  pulsating 
hematoma  following  injury  of  an  artery  (stab,  lacerated,  or  contused 
wound).  The  connective  tissue  surrounding  the  zone  of  infiltrated 
blood  becomes  thickened,  and  forms  a  sac  wall  within  which  the  blood 
burrows  a  hollow  space.  None  of  the  coats  of  the  artery  form  a  part 
of  the  sac  thus  formed. 

Simple  arterial  aneurism  occurs  more  frequently  in  men  than  in 
women,  and  is  most  common  between  the  ages  of  thirty  and  fifty. 
The  arteries  are  involved  in  the  following  order  of  frequency:  the 
thoracic  aorta,  the  popliteal,  the  femoral,  the  abdominal  aorta,  the 
carotid,  subclavian,  innominata,  axillary,  and  iliac.  Of  the  arteries 
of  organs,  those  of  the  brain  are  most  often  affected. 

The  structure  of  an  aneurismal  sac  varies.  In  true  aneurism  the 
walls  of  the  distended  vessel  are  thinned  out  by  the  causative  patho- 
logical process.  In  dissecting  aneurism  the  tunics  of  the  vessel  are 
separated  from  each  other  by  blood,  and  in  hernial  aneurism  the  wall 
is  composed  of  intima.  Inflammatory  proliferation  may  cause  thick- 
ening of  the  sac  and  its  adhesion  to  surrounding  tissues. 

The  sac  of  false  aneurisms  is  not  lined  by  endothelium  and  is  formed 
by  coarse  connective  tissue  b}'  which  it  is  intimately  associated  with 
the  surrounding  tissues.  Large  aneurisms  are  lined  with  layers  of 
thrombi,  which  not  only  protect  the  wall  of  the  sac  from  rupture,  but 
also  obliterate  the  branches  of  the  affected  vessel  and  may  be  the  origin 
of  emboli. 

The  sizes  of  aneurisms  vary  wnth  the  caliber  of  the  affected  artery. 

The  onset  of  aneurism  is  gradual,  even  in  the  case  of  the  false 
variety,  as  the  surrounding  tissues  exercise  control  of  the  quantity 
of  effused  blood.  The  development  or  growth  of  an  aneurism  is  also 
slow  (except  in  the  case  of  a  mycotic  aneurism),  and  is  often  inter- 
rupted by  the  formation  of  thrombi  or  the  occurrence  of  an  inflam- 
matory thickening  of  the  sac. 

Symptoms  of  aneurism  become  manifest  when  a  tumor  is  visible  or 
palpable,  and  when  pressure  causes  disturbance  in  surrounding  parts. 
The  tumor  is  round  or  oval  and,  when  not  too  deeplj^  located,  may 
present  visible  and  palpahle  pulsation.  The  pulsation  lifts  the  sur- 
rounding skin  and  enlarges  the  sac  in  all  directions  {expansive  pulsa- 
tion) ,  a  characteristic  which  does  not  obtain  in  tumors  lying  in  contact 


980     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

with  arteries.  Palpation  elicits  a  soft  thrill  or  fremitus  which,  upon 
auscultation,  is  found  attended  with  a  Mowing  or  buzzing  sound 
called  bruit.  The  latter  is  usually  systolic  but  may  be  diastolic,  and 
is  caused  by  blood  entering  and  leaving  the  sac.  The  tumor  may  be 
caused  to  dinmiish  in  size  by  central  compression  of  the  vessel,  but  is 
reestablished  when  the  pressure  is  released.  Distal  pressure  causes  an 
increase  of  size  and  tension  in  the  tumor. 

All  of  these  symptoms  may  be  diminished  or  absent,  when  the 
interior  of  the  sac  is  lined  by  a  thick  layer  of  fibrin. 

The  distal  pulse  is  weaker  than  that  in  the  corresponding  artery  on 
the  healthy  side ;  the  sphygmographic  curve  is  lower  and  more  rounded 
at  its  dome. 

The  pressure  symptoms  provoked  by  aneurisms  relate  especially  to 
contiguous  nerves  and  consist  of  sensory  disturbances,  gradually 
increasing  pain,  anesthesia,  parathesia,  and  motor  paralysis.  Pressure 
upon  veins  produces  stasis,  which  causes  visible  increase  in  the  size  of 
superficial  veins  and  is  often  attended  with  edema. 

As  the  aneurism  increases  in  size,  the  various  symptoms  are  ampli- 
fied. Traumatic  aneurism  produces  symptoms  closely  allied  to  those 
described,  but  the  clinical  picture  is  usually  sudden  in  onset,  becomes 
less  manifest  for  a  few  weeks,  and  then  is  gradually  more  clearly 
defined  as  the  aneurism  is  more  and  more  distended. 

Spontaneous  obliteration  of  an  aneurism  takes  place  in  rare 
instances  and  occurs  as  the  result  of  the  filling  of  the  sac,  and  the 
distal  and  proximal  portions  of  the  artery  with  a  thrombus.  As  a 
rule,  however,  the  development  of  an  aneurism  is  gradually  progres- 
sive —  except  in  the  mycotic  form  —  and  ultimately  leads  to  rupture. 
The  steady  persistent  impact  of  the  pulsation  against  a  contiguous 
bone  causes  the  formation  of  a  hollow  as  the  latter  slowly  atrophies 
and  is  absorbed,  so  that  the  aneurism  may  force  its  way  through  the 
sternum  or  the  ribs  or  may  cause  the  bodies  of  the  vertebrae  to  disap- 
pear. Ultimately,  the  skin  is  reached  which  also  becomes  atrophic, 
finally  ruptures  and  fatal  exter^ial  hemorrhage  ensues.  When  the 
skin  is  subjected  to  long  pressure,  subcutaneous  phlegmonous  infection 
is  very  likely  to  complicate  the  picture. 

Rupture  of  the  aneurismal  sac  occurs  at  situations  w^here  the  blood 
flow  is  at  its  maximum,  so  that  the  deposit  of  layers  of  thrombi  does 
not  take  place.  Bleeding  into  the  pericardium,  the  pleural  and  the 
abdominal  cavities  is  not  uncommon,  and  is  in  each  instance  attended 
with  the  clinical  picture  of  internal  hemorrhage.     Cerebral  hemor- 


DISEASES  OF  THE  BLOOD  AND  LY:\IPH  VESSELS     981 

rhage  is  always  a  grave  menace  and  is  often  promptly  fatal.  The 
rupture  of  deep  seated  aneurisms  of  the  extremities  is  characterized 
by  gigantic  swelling,  and  is  often  attended  with  pressure  necrosis  of 
soft  parts  which  is  soon  followed  by  perforation  of  the  skin  and 
external  bleeding.  Hematomata  due  to  subcutaneous  rupture  of  an 
aneurism  in  the  neck  involve  grave  danger  of  death  from  strangula- 
tion. Rupture  of  an  aneurism  into  a  vein  produces  the  secondary 
form  of  arteriovenous  aneurism. 

Additional  complications  of  aneurisms  are  the  result  of  loosening  of 
portions  of  thrombi,  and  embolic  obstruction  of  peripheral  vessels  fol- 
lowed by  necrosis  (embolic  gangrene).  Gangrenous  processes  of  this 
sort  occur  promptly,  when  the  collateral  circulation  is  obstructed  by 
thrombi  or  as  the  result  of  arteriosclerosis. 

Arteriovenous  aneurisms  (Fig.  474)  are  divided  into  three  varieties. 

The  arteriovenous  aneurism  with  a  venous  sac,  so-called  varix 
aneurismaticus  of  Scarpa,  is  usually  caused  by  simultaneous  injury  of 
contiguous  arterial  and  venous  walls.  After  adherence  of  the  sur- 
rounding tissues,  the  arterial  flow  enters  the  vein  (arteriovenous 
fistula)  and  by  impact  causes  dilatation  of  the  distal  wall,  the  latter 
thus  establishing  a  varix.  Spontaneous  aneurismal  varix  is  rare  and 
follows  perforation  of  a  calcareous  or  ulcerated  arterial  area  which 
has  involved  the  vein  by  extension  of  the  process. 

The  wall  of  a  varix  is  usually  very  thin  and  is  separated  from  the 
surrounding  tissues. 

The  arteriovenous  aneurism  with  a  false  sac,  the  so-called  aneurisma 
varicosum  of  Scarpa,  follows  simultaneous  injury  of  contiguous  arte- 
ries and  veins,  but  the  communication  between  the  vessels  is  accom- 
plished through  the  medium  of  a  hematoma  and  is  not  direct.  Both 
the  vein  and  the  artery  communicate  with  the  'false  or  intermediate 
sac,  which  consists  of  fibrinous  deposits  and  of  connective  tissue  pro- 
liferation from  the  surrounding  soft  parts,  and  is  more  or  less  closely 
attached  to  neighboring  nerves  and  muscles.  Aneurisms  of  this  sort, 
at  times,  develop  in  amputation  stumps. 

The  arteriovenous  aneurism  with  an  arterial  sac  is  also  classed  with 
the  varicose  aneurisms.  The  condition  is  rare  and  is  due  to  the  pres- 
sure of  an  arterial  aneurism  against  the  wall  of  a  vein,  which  it  ulti- 
mately perforates  {secondary  arteriovenous  aneurism) . 

Special  forms  of  arteriovenous  aneurisms  develop  if,  in  addition  to 
the  perforation  of  corresponding  portions  of  the  walls  of  the  artery 
and  vein,  one  or  both  vessels  are  perforated  at  another  more  or  less 


982     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

remote  point.  Thus  the  vein  opposite  the  poiut  of  communication 
with  a  true  or  false  sac  may  develop  a  varix;  the  artery  may  develop 
a  false  aneurism  or  a  varix,  or  an  aneurism  and  a  varix  may  be  com- 
bined in  the  same  case  (Fig.  474,  b). 

The  most  conwion  causes  of  arteriove^ious  aneurism,  are  perforating 
wounds  made  with  sharp  instruments  such  as  aspiration  needles,  bayo- 
nets, lances,  and  projectiles.    Of  159  cases  collected  by  v.  Bramann,** 

A    V  A     V  A  V  A 


\^ 


D 


Inl 
O 


Fig.  474a. —  The  Pkincipal  Three  Forms  of  Arteriovenous  Aneurism. 

1.  Arteriovenous  fistula  (a).  Arteriovenous  aneurism  with  venous  sae,  varix 
aneurismaticus  {h).  2.  Arteriovenous  aneurism  with  false  intermediate  sac, 
aneurisma  varicosum.  3.  Arteriovenous  aneurism  with  arterial  sac,  secondary 
arteriovenous  aneurism. 


A     V 


b  d 


A 


I 


dl 


nl 


/i\ 


CD 


Fig.  474&. —  Special  Forms. 

1.  Arteriovenous  aneurism  with  false  sae  and  varix  on  outer  side  of  the  vein. 
Single  injury  of  the  artery,  double  injury  of  the  vein.  2.  Arteriovenous  aneurism 
witli  direct  communication  in  (a)  and  with  a  false  intermediate  sae  in  {h)  and 
with  a  false  arterial  aneurism.  (Single  injury  of  vein,  double  injury  of  artery.) 
3.  Arteriovenous  fistula,  following  double  injuries  of  both  vessels.  The  sacs  lie 
opposite  each  other. 

108  followed  injury  with  cutting  instruments,  and  29  were  sequential 
to  gunshot  wounds.  According  to  Bevan,^  the  lesion  may  be 
congenital. 

The  occurrence  of  arteriovenous  aneurism  is  only  pos<sible  when  the 
vessels  are  injured  by  small  penetrating  objects,  and  when  repair 
takes  place  without  inflammation  (v.  Bergmann^").  In  stab  wounds 
rapid  repair  of  the  surface  wound  is  necessary.     When  the  walls  of 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     983 

the  vessels  are  not  completely  divided,  the  communication  is  established 
as  the  result  of  a  necrotic  process  involving  the  uninjured  portion,  in 
the  same  way  as  arteriovenous  aneurism  follows  severe  subcutaneous 
contusion  of  vessels  (v.  Bramann^). 

According  to  Delbet,^^  the  vessels  are  involved  in  arteriovenous 
aneurisms  in  the  following  order  of  frequency:  the  brachial,  femoral, 
popliteal,  carotids;  the  arteries  of  the  head  (especially  the  temporal), 
the  subclavian,  and  the  axillary.  This  form  of  aneurism  occurs  spon- 
taneously in  the  thoracic  and  abdominal  aorta,  and  in  the  interyial 
carotid  near  the  cavernous  sinus,  with  or  without  previous  trauma. 

The  size  of  the  sacs  is  variable  and  depends  upon  the  rapidity  of 
growth  and  the  diameter  of  the  perforation.  At  times,  they  reach  the 
size  of  a  hen's  egg  in  a  few  days,  though  this  is  rare,  the  average  size 
being  much  smaller.  A  venous  sac  or  varix  is  characterized  by  a  thin, 
more  or  less  movable  wall,  and  is  attended  with  dilatation  of  neigh- 
boring veins ;  a  false  sac  is  usually  attached  to  its  surroundings. 

The  manifestations  of  arteriovenous  aneurism  differ  from  those  of 
simple  aneurism,  as  the  arterial  blood  flows,  in  part,  into  the  vein. 
The  lesion  is  attended  with  hruit,  pulsation,  and  venous  stasis  with 
phlehectasia.  With  regard  to  the  other  symptoms,  the  picture  is 
similar  to  that  of  pure  arterial  aneurism. 

The  hruit  is  continuous,  though  somewhat  increased  in  intensity 
during  systole,  is  audible  at  its  maximum  immediately  over  the  lesion, 
and  is  conveyed  both  peripherally  and  centrally.  It  may  be  described 
as  loudly  sighing  or  rustling  in  character.  The  forcible  projection  of 
the  blood  into  the  vein  produces  a  peculiar  concussion  of  the  walls  of 
the  vessels,  which  is  transmitted  to  the  surrounding  soft  parts  and  is 
distinctly  palpahle  over  the  site  of  the  vascular  communication,  becom- 
ing less  so  in  both  directions.  The  sensation  imparted  to  the  hand  is 
varyingly  described  as  trembling,  purring,  fluttering  (v.  Bramann,* 
Franz'-). 

Pulsation  is  not  restricted  to  the  sac  but  is  conveyed  in  the  course  of 
the  vein  in  both  directions.  "Where  the  communication  between  the 
artery  and  the  vein  is  direct  the  latter  is  more  dilated  than  when  an 
intermediate  sac  is  present,  and  the  pulsation  is  more  marked  in  the 
former  class  of  cases.  Dilatation  is  visible  in  superficial  veins  in 
situations  where  the}'  anastomose  directly,  and  to  a  great  extent,  with 
the  site  of  the  lesion  (Fig.  475).  Central  occlusion  of  the  artery 
arrests  the  pulsation  and  abolishes  the  bruit.     When  it  is  possible  to 


984     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

obliterate  the  sac  by  pressure  against  the  bone,  the  distal  circulation 
may  reassume  normal  characteristics  (v.  Bramann*). 

Venous  stasis  is  manifested  in  the  venous  circulation  communicating 
with  the  site  of  the  lesion,  and  is  characterized  at  first  by  edema  and 
by  enlargement  of  the  subcutaneous  veins.  Later,  this  zone  becomes 
dark  bluish  red  in  color,  and  the  subcutaneous  tissue  is  infiltrated  by 
proliferated  connective  tissue  in  a  manner  similar  to  what  obtains  in 
elephantiasis  (pachy derma  acquisita).  The  effects  of  prolonged  stasis 
are  nutritional  in  character  and  are  evinced  by  numbness,  tingling,  a 
tendency  to  eczema  and  furunculosis,  atrophy  of  muscles,  and,  at 
times,  by  complete  loss  of  function  of  the  part.  In  rare  instances 
necrosis  suiDervenes.     Severe  modification   of  function  occurs  when 


Fig.  475. —  Dilated  Veins  in  Connection  with  Arteriovenous  Aneurism  op 

THE  Femoral  Vessels. 


the  causative  factor  simultaneously  injures  large  nerve  trunks,  or 
when  the  sac  makes  prolonged  pressure  on  nerves  supplying  important 
parts  or  organs.  The  latter  is  especially  noticeable  in  connection  with 
arteriovenous  and  arterial  aneurisms  situated  in  the  neck. 

The  outlook  in  cases  of  arteriovenous  aneurism  is  unfavorable  (v. 
Bramann^).  Although  a  sac  may  persist  for  years  without  a  fatal 
outcome,  there  is  no  likelihood  of  spontaneous  cure.  In  addition  to 
this,  the  nutritional  disturbances  attendant  upon  the  lesion,  the  con- 
stant danger  of  sudden  increase  in  size  of  the  sac  and  the  menace  of 
intercurrent  phlegmonous  infection  consequent  to  relatively  slight 
trauma,  and  lastly,  the  possibility  of  rupture,  render  the  condition  a 
most  serious  one. 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     985 

Differentiation  between  arterial  and  arteriovenous  aneurism  is  not 
difficult  in  typical  cases,  especially  when  the  latter  follows  soon  after 
trauma.  An  aneurismal  varix  may  be  distinguished  from  a  varicose 
aneurism  by  the  fact  that  the  venous  disturbances  are  more  marked 
in  the  former  than  in  cases  of  varicose  aneurism.  When  a  varix  is 
palpable  it  is  distinctly  softer  and  more  readily  compressible  than  the 
false  sac  of  a  varicose  aneurism.  The  diagnosis  of  aneurism  of  the 
thoracic  aorta  must  depend  largely  upon  physical  signs  and  the  X-ray 
examination,  unless  the  sac  has  perforated  the  chest  wall,  when  recog- 
nition of  the  process  should  not  be  attended  with  difficulty,  except, 
perhaps,  with  regard  to  acute  or  chronic  alscesses  in  cases  in  which 
the  sac  wall  is  inflamed,  though  the  latter  problem  comes  under  con- 
sideration in  connection  with  inflamed  aneurism  in  other  situations. 

Spontaneous  aneurisms  and  those  filled  with  layers  of  fibrin  may 
escape  recognition  for  a  long  time,  especially  when  pressure  symptoms 
are  absent. 

Tumors,  areas  of  infiltrated  tissues,  and  abscesses  lying  in  contact 
with  large  arteries  (gastric  carcinoma,  horseshoe  kidney,  inflammatory 
infiltrates,  tuberculous  abscesses,  enlarged  glands,  etc.)  may  simulate 
aneurism  because  of  the  pulsation  conveyed  to  them,  but  aneurism 
should  be  excluded  on  the  ground  of  the  absence  of  the  expansive 
element  in  the  pulsation  and  of  bruit. 

Angioma  cavernosum  may  be  recognized  by  its  flahhy  consistency 
and  the  blue  color  of  the  superimposed  skin;  and  angioma  racemosum 
is  readily  identified  by  the  visibly  serpentine  character  of  the  enlarged 
artery  and  veins.  Pulsating  sarcoma  is  not  easily  distinguished  from 
arteriovenous  aneurism. 

The  aim  in  the  treatment  of  simple  and  arteriovenous  aneurism,  at 
this  writing,  is  completely  or  partially  to  extirpate  the  sac;  central 
and  peripheral  ligature  of  the  artery  (also  the  vein  in  arteriovenous 
aneurism),  and  ligature  of  the  communicating  branches,  or,  what  is 
more  advisable  —  though  unfortunately  not  feasible  in  many  instances 
—  the  reestahlishment  of  the  normal  route  of  the  circulatory  fluid  by 
suture  (Matas^^). 

Complete  extirpation  of  an  aneurism  w^as  first  employed  by 
Philagrius  (in  the  fourth  centurj^)  and  again  brought  into  prom- 
inence by  Purrmann  in  1699  (Moynihan^*).  After  the  part  is  exsan- 
guinated with  the  V.  Esmarch  bandage  the  arterv^,  together  with  the 
sac,  is  exposed,  the  vessel  doubly  deligated  at  its  central  and  peri- 
pheral portions  and  divided  between  the  ligatures.     The  aneurism  is 


986    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


then  extirpated.  In  false  aneurisms,  which  are  usually  intimately- 
associated  with  the  surrounding  tissues,  it  may  be  necessary  to  leave 
portions  of  the  sac  in  situ  in  order  to  preserve  important  nerves  and 
veins.  The  method  has  been  successfully  employed  in  arteriovenous 
aneurism  (v.  Bramann,^  v.  Bergmann^").  The  danger  of  necrosis 
from  circulatory  disturbances  ( Wolff ^•^)  is  lessened  by  the  subsequent 
elevation  and  immobilization  of  the  limb.  It  would  seem  that  the 
employment  of  digital  compression  before  the  operation  has  a  tendency 
to  improve  the  collateral  circulation  (see  below). 

The  ideal  operation  for  the  relief  of  aneurism  comprises  extirpation 
of  the  sac  and  repair  of  the  vessel  ly  suture,  so  that  the  circulation  is 
reestablished.  In  cases  of  arteriovenous  aneurism  it  is  desirable  that 
the  solution  of  continuity,  in  both  the  artery  and  the  vein,  be  closed 
by  suture  (Zoge  v,  Manteufel,  Korte,  Garre,  quoted  by  Tscher- 
niachowsky^*^).  Matas^^  uses 
portions  of  the  sac  for  the 
purpose.  When  resection  of 
the  sac  is  necessary  the  ves- 
sels may  be  united  by  end  to 
end  anastomosis  (Murphy," 
Lexer^*).  This  has  been  ac- 
complished over  an  interven- 
ing space  of  6  to  8  cm.  When 
the  stumps  are  too  widely 
separated,     the     intervening 

area  may  be  bridged  by  implantations  of  arteries  or  veins  taken  from 
another  portion  of  the  patient's  body  (Lexer^^), 

Arteriorrhaphy  (Fig,  476),  or  repair  of  an  artery  by  suture,  is,  of 
course,  less  likely  to  be  successful  in  connection  with  aneurism  than 
obtains  in  cases  in  which  healthy  vessels  are  injured,  as  repair  of 
pathological  tissue  is  always  of  doubtful  outcome  and,  with  the  excep- 
tion of  arteriovenous  aneurism  following  trauma,  the  causative  patho- 
logical condition  in  aneurism  is  rarely  limited  to  the  site  of  the  aneu- 
rismal  sac.  Figure  476  portrays  the  complete  technic  of  the  pro- 
cedure. Gluck^^  reinforces  the  site  of  the  suture  line  by  a  cylinder  of 
decalcified  bone,  ivory  or  rubber. 

Matas'  operation^^'"^^  {aneurismorrhaphy) ,  described  by  himself  in 
1902,  is  performed  in  two  waj^s.  One,  called  ohliterative  endo-aneuris- 
morrhaphy  without  arterioplasty ,  is  applicable  to  fusiform  aneurism 
(Fig,  477).    No  attempt  is  made  to  reconstruct  the  parent  artery,  and 


Fig.    476. —  Kepair   of   Artery   after   Ex- 
tirpation OF  Aneurismal  Sac. 
The    serous    coats    are    made    to    lie    in 
apposition. 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS    987 


the  arterial  orifices  are  obliterated  by  suture  (Figs.  478,  479,  480, 
481).  The  illustrations  and  the  subjoined  legends  convey  an  adequate 
idea  of  the  technic  of  the  procedure.  The  sac  is  excluded  from  direct 
circulation  without  disturbing  adjacent  collateral  branches  and  with- 
out interfering  with  the  nutrition  of  the  sac  walls.  Nutritional  gan- 
grene and  secondary  bleeding  or  relapse  do  not  follow  the  operation. 
The  second  operation,  applicable  to  sacculated  aneurisms  in  which 

there  is  one  orifice  of 
communication  with 
the  artery  (Fig.  482), 
is  called  aneurismor- 
rhaphy  with  partial 
arterioplasty.  The  sac 
is  opened,  clots  are 
washed  away,  and  the 
opening  of  the  aneur- 
ism into  the  artery  is 
closed  as  shown  in  con- 
nection with  fusiform 
aneurism.  Blood  is 
thus  excluded  from  the 
sac  and  the  lumen  of 
the  artery  is  preserved. 
It  is  not  probable  that 
the  artery  remains 
patent  long,  because 
the  seat  of  the  aneur- 
ism is  a  diseased  vessel 
and  the  pathological 
process  will  probablj^ 
cause  clotting,  but  even 
tempor>ary  mainte- 
nance  of   the   circula- 


FiG.  477. —  The  Interior  of  a  Fusiform  Aneur- 
ISMAL  Sac,  Showing  Openings  and  Groove  op 
Main  Vessel  and  Opening  of  Collateral, 
Branch  (Matas). 


tion,  if  followed  by  gradual  obliteration,  tends  to  obviate  nutritional 
gangrene.  The  operation  may  be  regarded  as  superior  to  extirpation 
of  the  sac,  because  it  does  not  destroy  the  vascular  walls,  the  residual 
blood  vessels  of  which  aid  in  preventing  gangrene. 

Matas  emphasizes  that  his  operations  are  indicated  only  under  the  follow- 
ing conditions  : 

1.     The  situation  of  the  aneurism  must  permit  of  temporary  control  of  the 


DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


circulation  on  the  central  side  of  the  sac.  In  aneurisms  of  the  extremities 
this  is  accomplished  by  means  of  the  v.  Esmareh  constrictor.  In  the  neck 
and  abdomen  both  the  central  and  distal  portions  of  the  vessel  must  be  secured 
by  traction  loops  and  corai:)ression. 

2.  The  sac  must  be  freely  opened  in  a  longitudinal  direction.  Its  walls 
must  be  intact  and  must  not  be  traumatized  by  separating  them  from  the 
surrounding  tissues. 

3.  Every  orifice  opening  into  the  sac  must  be  exposed  so  that  they  may  be 
closed  by  suture. 

"Whether  extirpation  should  be  followed  by  arteriorrhaphy  or  liga- 
ture of  the  stumps  of  the  artery  depends  upon  the  collateral  circula- 
tion. The  extent  of 
the  collateral  circu- 
lation may  be  re- 
garded as  sufficient 
to  permit  of  repair 
by  suture,  when  the 
peripheral  opening 
into  the  sac  bleeds 
freely  (Henle-^) 
and  when  temporary 
compression  of  the 
vein  is  promptly  fol- 
lowed by  its  disten- 
tion with  blood  from 
the  periphery  (v. 
Frisch^'). 

Incision  of  ihc  sac 
and  removal  of  the 
'blood  clots  after 
ligature  of  the 
artery  (and,  if  nec- 
essary, the  vein) 
above  and  below  the 
aneurism  is  em- 
ployed, when  the 
aneurism  is  large 
and    extirpation    is 

impractica'ble.  The  openings  of  collateral  branches  into  the  sac  are 
closed  by  circular  suture  and  the  cavity  tamponed.  The  prolonged 
period  of  healing  may  be  shortened  by  making  a  small  incision  into  the 


Fig.  478. —  The  Fusiform  Aneurism, 

The  first  row  of  sutures  closing  the  orifices  by 
fine  chromicized  catgut  or  silk   (Matas). 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     989 


sac  and  by  the  employment  of  pressure  with  bandages  after  the  sac  is 
cleared  of  clots  (v.  Mikulicz,  quoted  by  Hofmann'^*).  Lexer"  reports 
observing  recurrence  after  the  method. 

Halsted's  method  of  partial,  progressive,  and  finally  complete  oc- 
clusion htj  metal  hand  is  applied  to  the  aorta  and  other  large  vessels. 
The  method  is  the  outcome  of  the  endeavor  of  a  number  of  surgeons 

in  this  direction,  and, 
as  modified  and  im- 
proved  by  Halsted, 
\v  0  u  1  d  seem  to  be 
worthy  of  considera- 
tion. 

Halsted-'  uses  a 
band  of  aluminum 
curled  in  cylinder  form 
around  the  vessel.  The 
band  is  caused  to  par- 
tially occlude,  and 
seldom  causes  macro- 
scopic changes  in  the 
wall  of  the  A-essel ; 
when  used  to  com- 
pletely^ occlude,  the 
vessel  ma}'  undergo 
atrophy.  The  intent  of 
the  measure  is  to 
nearly,  but  not  quite, 
occlude  the  vessel,  and 
is    followed    by    spon- 

The    second   row   of   sutures.       These   may   be    the    taneous    obliteration 
interrupted    or    continuous.       If   tloor   be    rigid,    the 
second  row  may  be  omitted  (Matas).  and   conversion    of  the 

portion  of  the  arterj^ 
surrounded  by  the  band  into  a  ''solid  cylinder  of  living  tissue."  The 
originator  of  the  method  has  employed  it  with  success  in  the  human 
being,  once  on  the  innominate  and  four  times  on  the  carotid  arteries. 
Central  arterial  ligature  (close  to  the  aneurism,  after  Anel ;  some 
distance  from  it,  after  Hunter)  is  followed  by  shrinkage  of  the  sac; 
however,  the  collateral  circulation  often  causes  return  of  pulsation 
and  the  deposit  of  new  coagulum,  from  which  emboli  are  not  infre- 
quently separated,  giving  rise  to  emholic  gangrene.     The  method  is 


Fig.  479. —  The  FusiroBM  Aneurism. 


990    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

objectionable  in  cases  of  arteriovenous  aneurism,  as  it  is  frequently 
followed  by  gangrene  of  the  distal  part ;  when  the  collateral  circula- 
tion is  fully  established,  the  blood  enters  the  vein  from  the  artery 
below  the  seat  of  ligature  and  little,  if  any,  is  conveyed  to  the  peri- 
phery. 

Central  and  peripheral  ligature  of  the  artery  and  vein  for  the 


Fig.  480. —  The  Fusiform  Aneurism. 

The  second  row  of  sutures  (continuous)  introduced; 
the  final  obliterating  sutures  passed  at  either  side. 
On  the  left,  transfixion  of  floor  13  made.  On  the 
right,  ends  of  similar  sutures  passed  through  integu- 
ments (Matas). 

relief  of  arteriovenous  aneurism  is  followed  by  better  results.  The 
vessels  are  exposed,  doubl}^  deligated,  and  divided  between  the  liga- 
tures; the  site  of  the  lesion  is  not  disturbed.  As  the  branches  of  the 
vessels  are  not  occluded,  recurrence  is  not  uncommon. 

The  peripheral  arterial  ligature  of  Brasdor  and  Wardrop  (Figs. 
485-486)  is  employed  for  the  relief  of  aneurism  so  situated  that  the 
central  ligature  is  impossible,  such  as  the  innominate  or  the  ascend- 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     991 

ing  aorta.  The  obstruction  to  the  circulation  tends  to  promote  the 
formation  of  coaguli  in  the  sac. 

The  occurrence  of  traumatic  aneurism  may  he  prevented  by  repair 
of  the  injured  vessel  b}'  suture  as  soon  as  a  pulsating  hematoma  is 
formed. 

The  technic  of  phleborrhaphy  is  shown  in  Fig.  487;  that  of  repair 
of  a  longitudinal  -wound  of  an  artery  in  Fig.  488.    Both  measures  are 


Fig.  -481. —  The  Fusiform  Aneurism. 

The  deep  supporting  sutures  in  place,  and  passing  their  end.?  through  skin  and 
aneurismal  wall. 

not  infrequently  used  in  repairing  vessels  injured  while  removing 
neoplasms. 

A  sutured  artery  will  carry  hlood  in  most  cases,  but  only  for  a  time; 
ultimately  the  vessel  is  obliterated  by  endothelial  proliferation.  How- 
ever, the  temporary-  maintenance  of  the  circulation  gives  opportunity 
for  the  gradual  development  of  sufficient  collateral  circulation  to 
obviate  gangrene  of  the  distal  part.  There  is  also  some  danger  of 
the  development  of  aneurism  at  the  site  of  the  repair,  so  that,  after 
all,  the  measure  is  not  without  its  disadvantages. 


992     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


Amputation  is  resorted  to  in  eases  of  large  aneurisms  of  the  ex- 
tremities and  when  embolic  and  nutritional  gangrene  is  established. 

Inoperable  aneurisms  and  aneurisms  in  inaccessible  situations  may 
be  treated  by  measures  which  tend  to  increase  the  deposit  of  thrombi 
in  the  sac  and  thus  prevent  its 
growth  and  lessen  the  likelihood 
of  rupture. 

Co7istant  or  intermitteyit  com- 
pression of  the  proximal  portion 
of  the  artery,  digital  or  by 
means  of  apparatus,  is  at  times 
effectual.  The  pressure  should 
be  sufficient  to  abolish  pulsation 
in  the  sac,  but  must  not  cause 
stasis  in  the  limb ;  therefore,  cir- 
cular constriction  must  not  be 
employed.  In  this  way  simple 
aneurism,  has  been  made  to  dis- 
appear permanently  in  a  few 
hours,  though  in  some  cases  days 
and  weeks  of  intermittent  com- 
pression have  been  necessary  to 
accomplish  the  purpose.  The 
circulation  is  carried  on  through 
the  layers  of  fibrin.  In  arterio- 
venous aneurism  the  artery  is 
compressed  close  to  the  lesion 
until  pulsation  is  abolished ; 
thereupon,      the      other      hand 

presses  the  aneurism  against  the  Fig.  482.—  Thk  Sacciform  Aneurism,  its 
,  -.i    ,1        •  r.  •        •  Main  ORiricE  axd  the  Dotted  Outline 

bone  with  the  view  of  causing  its      of  the  Main  Vessel  (Matas). 

obliteration.      The   method    has 

been  successful  in  cases  of  small  aneurisms.  Compression,  together 
with  rest  in  bed,  should  be  emploj-ed  for  a  brief  period  of  time 
preliminary  to  operative  efforts  at  relief.  Though  the  measure  may 
not  be  productive  of  healing  of  the  aneurism,  it  aids  in  the  develop- 
ment of  the  collateral  circulation  and  tends  to  obviate  the  occurrence 
of  postoperative  gangrene.  In  certain  portions  of  the  body  (elbow, 
groin,  and  knee)  compression  may  be  executed  by  immobilization 
of  the  part  in  hyperflexion,  but  the  measure  should  be  used  only  in 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     993 


Fig.  483. —  Axel's  Operatiox  for  AxErRisir 


connection  with  small  aneurisms;  in  larger  ones  it  may  cause  rupture. 
The  latter  danger  exists  also  when  direct  pressure  is  made  upon  the 
sac  with  the  hands  or  apparatus. 

The  gelatin  treatment,  by  means  of  subcutaneous  injection  of  one 
to  two  per  cent  gelatin  solution,  rests  on  the  experience  of  Dastro  and 
Floresco  (Sargo-*^),  who  showed  that  blood  of  animals  thus  injected 

had  its  period  of 
coagulabilit}'  short- 
ened. One  hun- 
dred c.cm.  of  the 
solution  is  injected 
once  a  week.  Beck-' 
reports  a  case  of 
large  aortic  aneur- 
ism cured  by  this 
method  in  two  months.  In  cases  of  cardiac  feebleness,  the  measure 
has  caused  the  formation  of  thrombi  in  apparently  normal  veins 
(iliac,  femoral).  Bass-*  warns  that  thorough  sterilization  is  neces- 
sary, with  the  view  of  preventing  tetanus. 

Of  the  other  methods  of  treatment,  the  injection  of  chemicals  and 
the  compression  of  an 
entire  limb  by  means 
of  elastic  bandages  are 
justly  condemned  be- 
cause of  the  danger  of 
necrosis.  Acupuncture 
with  glowing  needles, 
galvanopuncture,  and 
the  introduction  of  gold 
wire  have  been  used  in 
efforts  to  afford  relief  in 
aortic  and  abdominal 
aneurisms.  None  of 
these  is  without  danger  of  inflammation,  bleeding  and  the  liberation 
of  emboli,  nor  does  it  seem  that  the  measures  are  followed  by  suf- 
ficient relief  to  justify  exposure  to  the  risks. 

Eecently,  Lusk-^  has  devoted  considerable  effort,  both  experiment- 
ally and  clinicall}',  to  establish  the  value  of  the  use  of  gold  wire  in 
cases  of  aortic  aneurism ;  his  conclusions  would  seem  to  discourage  a 
revival  of  the  method. 


^% 


Fig. 


484. —  Hunter's  Method  of  Ligature  for 

AXEURISil. 

a,   The   aneurism;    h,  point  of  ligature;    e,  the 
branches  between   the  ligature  and  the  aneurism. 


994    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


The  general  treatment  of  aneurism  is  based  on  the  widely  accepted 
notion  that  lues  is  the  most  frequent  causative  factor.     The  import- 
ance of  the  persistent  use  of  antisyphilitic  treatment  is  emphasized  by 
Lusk.^^    Enforced  rest  and  the  avoid- 
ance of  conditions  which  tend  to  raise 
blood  pressure   (alcohol,  excitement) 
are    of    value.      Starvation    of    the 
patient  is  not  based  on  scientific  data 
and  should  be  avoided.     The  use  of 
digitalis    and    strophanthus    would 
seem  to  be  of  service. 

Phlebectases,  Varices. — Phlebectases, 
or  varices,  also  called  varicose  veins, 
may  be  defined  as  a  permanent  "dila- 
tation of  veins.  They  are  classified  in 
accord  with  their  forms  as  spindle 
shaped,  cylindrical,  and  tortuous  {cir- 
soid) .  Circumscrihed  sacculation  of  a 
vein  is  called  a  varix.  However,  as  the 
various  forms  merge  into  one  another, 
the  terminology  is  not  clearly  defined. 

The  causation  of  varicosities  is  dependent  upon  a  number  of  factors. 
Besides  mechanical  obstruction,  which  interferes  with  the  emptying  of 
the  veins  and  increases  the  blood  pressure,  the 
lessened  elasticity  of  their  walls  and  valves  — 
which  may  be  congenital  or  the  result  of  chronic 
inflammatory  processes,  must  be  considered. 
As  a  rule,  a  number  of  etiological  factors  are 
combined,  one  following  and  accentuating  the 
other.  For  example,  when  the  valves  of  the 
veins  of  the  lower  extremities  have  undergone 
deformation  and  are  insufficient,  the  weight  of 
the  column  of  blood  of  the  trunk  is  thrown 
upon  the  wall  of  the  vein.  Per  contra,  if  the 
walls  of  the  veins  are  distended  hy  prolonged 
stasis,  the  valves  become  insufficient  and  are  no 
longer  capable  of  assisting  in  relieving  the  vis 
a  tergo.    Long  continued  stasis  causes  the  walls 

486.— Wardrop's     ^^  *^®  ^^^^^  *"  become  inelastic  and  yielding. 
Operation.  and   the   circulation   in   the   vasa   vasorum   i"^- 


55. —  Brasdor's   Opera- 
tion. 


Fig. 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     955 


Fig.  487. —  Phleborkiiaphy. 
The  forceps  evert  the  edges  of  the  wound. 
The   sutures   appose   the   serous   surfaces   of 
the  intima. 


interfered  with  so  that  nutritional  changes  occur  which  are  followed 
by  dilation  of  the  vein  with  valvular  insufficiency.    The  importance  of 

the  valves  in  the  veins  as  aids 
to  the  circulation  has  been 
contested,  but  their  value  in 
this  connection  would  seem  to 
have  been  shown  by  Lowen- 
stein,^°  Normally  the  valves 
close  upon  slight  increase  in 
proximal  pressure  and  are 
able  to  resist  a  pressure  of  600 
mm.  of  a  column  of  mercury 
1  mm.  in  diameter. 

Pathological  examination  of 
a  varicose  vein  may  show  a 
portion  to  be  practically  normal,  while  other  segments  are  thickened 
as  the  result  of  the  replacement  of  muscular  and  elastic  fibers  by  pro- 
liferated connective  tissue  (fibrous  panphlebitis),  or  they  are  thinned 
out,  the  outcome  of  dilatation  atrophy.  The 
latter  condition  corresponds  to  sacciform 
enlargements,  which  are  usualh^  situated 
near  a  valve.  Varicose  veins  are  frequently 
more  or  less  wddely  adherent  to  the  con- 
tiguous tissues  in  response  to  nutritive 
changes  or  as  the  result  of  chronic  inflam- 
matory processes  of  the  perivascular  tissues. 
Proliferation  of  the  intima  narrows  the 
lumen  of  a  vein,  which  causes  slowing  of  the 
blood  stream  and  predisposes  to  the  forma- 
tion of  thromhi.  "When  thrombi  become 
calcified  the}'  are  called  phleholiths.  A  varix 
may  attain  the  size  of  a  hen's  egg,  and  when 
the  neck  of  the  protrusion  becomes  con 
stricted  takes  on  the  form  of  a  hlood  cyst. 
Large  serpentine  varicose  convolutions  of 
contiguous  veins  may  communicate  with 
each  other  as  the  result  of  pressure  atrophy 
{anasioif)iosing  varices). 

Phlebectases  involve  most  frequently  the 
hemorrhoidal  veins  and  their  plexus  at  the 


Fig.  488. —  Repair  of  Longi- 
tudinal Wound  of  an 
Artery. 

The  intima  is  everted  and 
the  sutures  arc  made  to  ap- 
pose the  serosa  of  the  vessel. 


996     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMOHS 


anus  (hemorrhoids).  The  dilatation  in  this  situation  is  attributed 
to  stasis  of  the  portal  circulation  due  to  pathological  processes 
in  the  liver  (Jounanne^^),  to  chronic  obstipation  and  to  inflam- 
mation of  the  mucuous  membrane.  Various  authors  (Reinbach, 
Gunckel,  Rotter,  and  Zeigler,  quoted  by  v.  Riidiger-Rydygier^^)  re- 
gard the  process  as  a  genuine  new- 
growth,  i.  e.,  angioma  cavernosum;  how- 
ever, this  view  would  seem  disproved  by 
the  work  of  v.  Riidiger-Rydygier.^- 

Next  in  frequency,  the  superficial  and 
deep  veins  of  the  lower  extremities  are 
affected,  the  process  usually  appearing 
in  middle  aged  perso7is  who  are  forced 
to  maintain  inactive  upright  positions 
over  long  periods  of  time  ;  in  women  who 
have  borne  many  children ;  in  cases  of 
tumors  of  the  pelvis;  and,  at  times,  in 
young  persons  with  inherited  weakness 
of  the  walls  of  veins.  Bluish  nodules, 
protuberances,  and  linear  elevations  ap- 
pear in  the  areas  over  the  major  and 
minor  saphenous  veins  which  are  visible 
through  the  thinned  out  skin.  The  en- 
gorged veins  may  be  emptied  hy  pres- 
sure and  by  elevation  of  the  limb  and  are 
refilled  from  the  periphery  when  the 
pressure  is  released  or  the  limb  lowered. 
When  the  valves  are  insufficient  the 
vessels  also  fill  from  the  central  end. 
The  dilated  fijie  veins  of  the  skin  appear 
in  the  form  of  reddish,  irregular,  ser- 
pentine streaks.  The  veins  of  the  arm 
are  rarely  affected,  but  may  become 
dilated  when  tumors  make  pressure  upon 
the  axillary  or  subclavian  vessels,  or  as  the  result  of  arteriovenous 
aneurism  involving  these  vessels. 

Varicosities  of  the  pampiniform  plexus  are  called  varicoceles  and 
are  as  frequent  in  youth  as  in  later  life.  The  condition  occurs  in  the 
bladder  in  connection  with  prostatic  hypertrophy  and  in  the  plexus 
uterovaginalis  vesicularis  pude7idalis  in  advanced  periods  of  life.    The 


4 

Fig.  489. —  Resected  Piece  op 
THE  Long  Saphenous  Vein 
(Filled  with  Paraffin). 

1,  cylindrical;   2,  fusiform;   3, 
tortuous   phlebectascs ;    4,  varix. 


JDISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     997 


veins  of  the  abdominal  wall  are  widely  dilated  in  the  region  of  the 
navel  {caput  Medusae)  in  cases  of  obstruction  of  the  portal  circula- 
tion (thrombosis,  cirrhosis  of  the  liver,  etc.)  and  may  be  regarded 
as  an  effort  to  establish  collateral  circulation.  Tumors  of  the  media- 
stinum may  cause  the  veins  of  the  chest  to  dilate  in  the  same  way. 

The  results  of  varicose  veins  are 
circulatory  and  nutritional  dis- 
turhances,  both  of  which  are  espe- 
cially manifest  in  the  lower  leg. 
The  skin  becomes  atrophic,  is 
readih^  traumatized,  is  exceedingly 
susceptible  to  infection,  and  is  very 
likely  to  become  necrotic.  Thus 
the  common  picture  of  varicose 
ulcer,  eczema,  and  thromhophle- 
hitis,  the  bane  of  the  public  clinics, 
is  developed.  To  this  is  added 
edema  and  thickening  of  the  skin 
and  subcutaneous  tissues  (elephan- 
tiasis phlehectasia) .  The  subjec- 
tive sjTnptons  consist  of  weakness 
and  fatigue  of  the  limbs,  the  result 
of  circulatory  disturbances,  fibrous 
myositis  and  degeneration.  "When 
the  deeper  veins  are  involved  the 
patient  suffers  with  neuralgic  pain ; 
the  latter  often  accompanies 
varicocele  (genitocrural  nerve). 
Atrophy  of  the  scrotum  occurs  in 
connection  with  varicocele,  and  a 
similar  condition  of  mucous  mem- 
branes develops  when  submucous 
veins  are  dilated. 

The  dangers  of  varices  relate  to 

thromhophlehitis  and  hemorrhage. 

The   latter    follows   rupture    of   a 

sacculated  dilatation  and  thinning  out  of  the  wall  of  the  vein  and 

superimposed  skin  or  mucous  membrane.     This  occurs  in  the  leg  and 

may  follow  faulty  application  of  the  v.  Esmarch  bandage.     Fatal 


Fig. 


"■'"^Stoist.- 


490. —  Varicose    Veins 
THE  Lower  Extremity. 


OF 


998     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

bleeding  from  a  lower  limb  is  rare,  though,  it  does  happen  in  connec- 
tion with  anal  or  rectal  varices,  and  with  those  situated  in  the 
esophagus  and  the  brain.  The  rupture  of  an  intramuscular  varicosity 
is  attended  with  sudden  sharp  pain  and  swelling. 

The  diagnosis  of  phlebectasis  and  varices  in  superficial  veins  is  not 
difficult.  The  circumscribed  form  may  be  confused  with  cavernous 
henmngioTna.  Deeply  located  lesions  do  not,  as  a  rule,  give  rise  to 
sjnnptoms.  The  peculiar  pulsation  of  an  arteriovenous  aneurism 
should  make  the  character  of  that  lesion  clear.  Varices  of  the  femoral 
canal  and  scrotal  varicocele  must  be  differentiated  from  hernia  in 
these  situations;  not  a  difficult  problem  when  it  is  remembered  that 
the  former  may  be  made  to  disappear  upon  pressure,  and  reappear 
when  the  pressure  is  released  or  w'hen  the  posture  of  the  patient  is 
changed  from  the  supme  to  the  erect. 

The  treatment  varies  with  the  cause,  the  location,  and  the  complica- 
tions of  the  process. 

Removal  of  a  tumor  which  makes  pressure  upon  the  trunk  of  a  vari- 
cose vein  is  usually  followed  by  arrest  of  the  process,  if  not  complete 
restitution  to  the  normal.  On  the  other  hand,  ligature  of  the  main 
trunk  of  the  saphenous  vein  is  of  benefit  when  the  valves  of  the  distal 
veins  are  insufficient. 

The  increase  in  the  size  of  phlebectases  and  varices  of  the  lower 
limbs  may  be  prevented  by  the  use  of  elastic  compression  in  the  form 
of  bandages  or  gum  elastic  stockings,  and  by  elevation  of  the  affected 
part.  The  latter  measure,  if  persisted  in,  will  make  the  subsequent 
use  of  compression  more  effective.  Varicocele  is  helped  by  the  use  of 
a  suspensorium.  This  may  be  supplemented  b}^  daily  immersion  of  the 
scrotum  in  cold  water. 

The  enlargement  of  the  subcutaneous  veins  of  the  pampiniform 
plexus  may  be  extirpated.  In  the  lower  limbs,  the  saphenus  major 
may  be  resected  or  deligated.  Pathological  branches  should  also  be 
removed  (Madelung,  quoted  b}^  F.  FraenkeP^).  Hesse  and  Schaak^* 
speak  well  of  the  method  of  Delbet,^^  who  divides  the  saphenous  at 
its  entrance  into  the  crural  canal,  resects  12-14  cm.  of  its  length,  and 
anastomoses  the  remainder  into  the  femoral  vein  with  the  view  of 
utilizing  the  valves  of  the  deeper  vessel.  Hemorrhoidal  dilations  are 
removed  by  cautery  or  are  extirpated  after  ligature  (Part  X^^II). 

Bleeding  is  at  times  controlled  by  simple  elevation  of  the  part  and 
the  use  of  moderate  pressure.  The  bleeding  from  prolapsed  and 
strangulated  piles  may  be  controlled  by  reduction  of  the  protrusion. 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     999 

The  treatmeut  of  the  complications,  such  as  ulcer,  infection,  etc.,  is 
taken  up  in  the  chapters  devoted  to  these  subjects. 

Thrombosis  and  Embolism. — The  coagulation  of  hlood  ivithin  the 
lumen  of  a  vessel  during  life  is  called  thrombosis;  the  coagulum  itself 
is  called  a  thrombus. 

Since  the  mechanism  of  thrombosis  was  first  described  by  Zahn^''  as 
observed  by  him  in  the  mesentary  of  the  frog,  thrombi  have  been 
classified  in  accord  with  their  color  as  white,  mixed,  and  red.  How- 
ever, all  fully  developed  thrombi  conform  to  the  general  rule  —  that 
the  relatively  small  head  of  the  coagulum,  which  points  in  the  direc- 
tion of  the  flow  of  the  blood  stream,  is  white ;  the  more  extensive  tail 
is  dark  red,  and  the  neck  or  intermediate  portion,  is  a  mixture  of 
the  two  colors.  This  is  quite  in  accord  with  the  development  of  a 
thrombus,  which  begins  with  the  white  portion  (Aschoff^*'). 

According  to  Bizzozero,  Eberth,  Schimmelbush,^^  and  others,  the 
formation  of  thrombi  is  preceded  by  slowing  of  the  blood  current  at 
an  area  in  a  vessel  where  the  endothelium  has  been  damaged  by  the 
action  of  chemical,  mechanical  or  pathological  irritation,  or  at  the 
site  of  a  valve  in  a  vein.  In  either  event,  blood  platelets  collect  at  the 
site  where  the  circulation  is  retarded,  become  adherent  to  one  another 
and  form  the  colorless  blood  platelet  thrombus  (Eberth 's^^  coagulation 
thrombus) .  Recent  observations,  especially  those  of  Schridde,  "Wright, 
and  Aschotf,^®  would  seem  to  show  that  blood  plates  are  neither  dis- 
integrated red  nor  white  blood  corpuscles,  nor  are  they  nucleated  cells 
(thrombocytes,  Dietjen^*),  but  are  independent  anatomical  elements 
taking  their  origin  by  cleavage  from  giant  cells  located  in  the  blood 
marrow  or  the  spleen.  The  formation  of  the  platelet  thrombus  is 
followed  by  the  coagulation  of  fibrin  precipitated  by  the  ferments 
liberated  by  the  blood  plates.  When  the  formation  of  coagulum  is 
restricted  to  the  plasma  zone  of  the  blood,  in  which  there  are  only 
white  corpuscles,  the  thrombus  remains  colorless;  in  other  instances, 
it  is  mixed,  and  then  there  is  a  clear  demarcation  in  the  arrangement 
of  the  corpuscular  elements,  the  thrombus  is  arranged  in  red  and 
white  layers.  To  these  forms  may  be  added  the  hyalin  thrombi  found 
in  the  smaller  vessels,  seemingly  a  peculiar  form  of  coagulation  con- 
sequent to  the  action  of  toxic  sub.stances  (snake  poison,  burns,  infec- 
tioua  diseases,  Dietrich^").  A  red  thrombus  develops  from  coagulation 
after  the  vessel  is  completely  closed  by  the  white,  and  is  formed  from 
blood  that  is  motionless,  and  therefore  consists  of  all  the  constituents 
of  the  circulating  fluid,  including  fibrin. 


1000    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

The  occurrence  of  coagulation  is  dependent  upon  the  presence  in 
the  blood  of  fibrin  ferment,  or  thrombin  (Alex  Schmidt*"),  a  substance 
formed  from  blood  platelets  and  from  disintegrated  red  and  white 
corpuscles  and  endothelial  and  tissue  cells,  which  acts  upon  the  fibrino- 
gen held  in  solution  in  the  plasma,  the  two  forming  an  albuminous 
substance.  The  development  of  fihrin  ferment  is  ascribed  to  the 
action  of  two  protein  bodies,  thrombogen  and  thrombokinase,  which 
act  in  the  presence  of  lime  salts  (Morawitz  and  Lossen*^).  The  lime 
salts  and  thrombogen  are  alwa^'s  present  in  circulating  blood,  while 
thrombokinase  is  given  up  only  under  special  conditions  (irritation 
of  a  foreign  substance)  by  the  platelets  and,  to  some  extent,  by  the 
leukocytes  and  is  taken  up  by  the  plasma.  It  is  probable  that  throm- 
bokinase is  a  general  protoplasmic  product  which  enters  the  blood 
from  the  disintegrated  tissue  cells  of  a  wound,  and  also  from  the  cells 
destroyed  in  inflammatory  processes. 

The  factors  concerned  in  the  formation  of  a  thrombus  are  (1) 
slowing  of  the  blood  current;  (2)  changes  in  the  walls  of  the  vessels; 
(3)  changes  in  the  blood. 

Slowing  of  the  blood  current  in  disturbances  of  the  circulation,  due 
to  cardiac  asthenia,  is  an  important  factor  in  so-called  7narantic  throm- 
hosis.  Local  interference  with  the  circulation  occurs  in  connection 
with  narrowing  of  the  lumen  of  vessels;  in  atherosclerosis ;  when  pres- 
sure is  made  upon  vessels  by  tumors,  dislocated  hones,  or  fragments  of 
fractures,  or  by  constricting  bandages;  and  the  development  of 
whirls  and  eddies  in  aneurisms  and  in  pouch-like  dilations  of  veins. 

The  changes  in  the  walls  of  vessels  may  consist  of  an  insignificant 
loss  of  the  endothelial  lining,  though,  of  course,  thrombosis  is  more 
likely  to  occur  when  the  injury  is  extensive.  Large  arteries  are  often 
closed  by  the  rolling  in  of  the  intima  following  lacerations  and  con- 
tusions, and  spontaneous  healing  of  smaller  wounds  is  not  infrequent. 
The  formation  of  thrombi  is  favored  by  changes  in  the  wall  of  the 
vessel  consequent  to  thermic  and  chemical  influences;  to  disease,  such 
as  atherosclerosis  and  bacterial,  purulent  and  tubercnlous  inflamma- 
tion; to  the  presence  of  foreign  bodies  (needles,  etc.),  and  to  tumorous 
infiltration. 

The  changes  in  the  blood  are  expressed  b}^  heightened  coagidability, 
due  to  increase  in  fibrin  ferment  consequent  on  the  disintegration  of 
numerous  cellular  elements.  The  latter  process  ma}^  be  coincident  to 
general  infections  of  various  kinds  (pyogenic  infections,  typhoid  fever, 


DISEASES  OP  THE  BLOOD  AND  LYMPH  VESSELS     1001 

influenza,  etc.),  to  diseases  of  the  hlood  (chlorosis)  and  may  occur  in 
cases  of  extensive  hums. 

The  more  marked  one  cause  is,  the  less  probable  is  the  existence  of 
the  others. 

A  thrombus  may  be  mural  or  obliterating.  It  may  be  restricted  to 
its  original  point  of  development  or  may  (without  becoming  attached 
to  the  vessel  at  all  points),  as  the  result  of  the  deposit  of  more  fibrin, 
extend  over  large  areas;  for  instance,  from  the  foot  to  the  vena  cava. 
On  section,  thrombi  often  have  a  streaked  appearance  and  present 
irregularly  mottled  light  and  dark  areas.  The  laminated  arrangement 
is  due  to  the  deposit  of  a  red  upon  a  white  or  mixed  thrombus.  The 
walls  of  aneurismal  sacs  are  laminated  when  the  deposit  of  thrombi 
is  intermittent.  In  this  way  a  layer  of  fibrin  may  become  firmly 
adherent  before  another  is  superimposed,  and  the  two  layers  may  be 
quite  independent  of  each  other. 

The  changes  occurring  in  a  thrombus  are  the  outcome  of  contraction 
of  the  fibrinous  network  by  which  its  fluid  constituents  are  expressed 
and  the  cellular  elements  destroyed.  Canalization  of  the  vessels  may 
result  from  this  process  of  shrinkage.  "When  a  large  thrombus  under- 
goes softening  in  its  center,  it  is  converted  into  a  grayish  red,  mushy 
mass,  consisting  of  disintegrated  cellular  elements,  from  which,  after 
dissolution  of  the  outer  layers,  smaller  particles  are  carried  into  the 
blood  stream,  giving  rise  to  embolism.  "When  the  thrombus  is  pyogenic 
or  putrefactive  in  character,  the  liberated  particles  convey  infectious 
excitants  to  various  parts,  organs,  and  tissues  of  the  bod}',  whefe  they 
give  rise  to  secondary  processes  (infectious  embolism).  The  most 
favorable  termination  of  a  thrombus  is  that  of  organization.  A  vascu- 
lar germinal  tissue  develops  from  proliferating  epithelium ;  it  invades 
and  replaces  the  thrombus  which  is  converted  into  firm  connective 
tissue,  permanently  closing  the  lumen  or  simpl}^  causing  a  thickening 
of  the  vessel  wall.  "When  lime  salts  are  deposited  in  a  thrombus  or  in 
the  tissues,  so-called  venous  or  arterial  stones  are  formed  {phelboliths 
and  arterioliihs) . 

Clinical  evidence  of  throvibosis  is  manifested  onJ]i  when  a^^large 
vessel  is  entireh/  obliterated.  Occlusimi  of  an  artery  is  followed  by 
modiflcation  of  the  peripheral  circulation  which,  when  the  collateral 
vessels  are  also  obstructed,  results  in  necrosis.  Venous  obstruction  is 
followed  by  stasis.  Very  often  symptoms  do  not  appear  until  embol- 
ism occurs. 

Arterial  thrombosis  attends  trauma,  aneurism,  acute  inflammatory 


1002     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

and  chronic  diseases  of  the  vessel  walls,  or  is  the  sequel  of  an  arrested 
embolus  orig-inating  from  the  heart  or  large  vessels. 

Ve^ious  thrombosis  often  occurs  in  conjunction  with  pJilehitis  and  is 
a  common  complication  in  prolonged,  exhaustmg  diseases  in  which  the 
heart  is  enfeebled,  and  the  constant  presence  of  toxins  in  the  blood 
favors  the  formation  of  thrombi.  The  latter  is  especially  likely  to 
happen  when  to  this  is  added  protracted  administration  of  narcotics 
in  connection  with  an  operation.  The  veins  of  the  legs  become  throm- 
bosed more  frequently  than  any  others  because  of  their  liability  to 
dilatation  and  the  frequent  occurrence  of  phlebitis  in  this  situation. 
Thrombosis  of  the  superficial  veins  is  manifested  by  the  appearance 
of  a  hard,  painful,  more  or  less  serpentine  thickening  of  the  vessel 
and  moderate  edema  of  the  limb.  When  the  femoral  vein  is  affected 
it  is  plainly  palpable,  the  thickened  and  hardened  vein  sometimes 
reaching  the  size  of  the  thumb ;  the  edema  is  considerable  and  the  limb 
becomes  cyanotic.  Thrombosis  of  the  pampiniform  plexus  follows 
trauma  during  operations  and  may  extend  to  the  femoral  by  way  of 
the  hypogastric  vein.  Severe  edema  of  one  or  both  legs  may  be  con- 
sequent to  thrombosis  of  the  uterine  veins  and  is  generally  known  by 
the  name  of  phlegmasia  alba  dolens.  This  condition  often  follows 
childbirth  and  is  not  rare  after  hysterectomy.  Infections  of  the 
middle  ear  are  a  frequent  cause  of  thrombosis  of  the  transverse  sinus, 
which  may  extend  to  the  brain  and  internal  jugular  vein.  Thrombosis 
of  mesenteric  veins  occurs  in  connection  with  strangulated  and  in- 
carcerated hernias,  and  extends  to  the  portal  system,  where  it  causes 
serious  stasis.  In  the  superior  and  inferior  vena  cava  and  in  the  sub- 
clavian vein,  thrombosis  occurs  by  extension  or  in  connection  with 
pressure  from  tumors  or  aneurisms.  Compensatory  dilatation  of  col- 
lateral veins  often  leads  to  recession  of  the  symptoms.  Necrosis  occurs 
when  all  the  veins  of  a  sector  are  obstructed. 

Every  thrombus  involves  danger  of  embolism.  Separation  of  an 
embolus  may  follow  trauma  or  sudden  exertion  or,  in  instances  of 
purulent  softening,  may  occur  spontaneously.  The  head  of  a  throm- 
bus extending  from  a  smaller  branch  into  the  lumen  of  a  large  vessel 
may  be  carried  away  by  the  forceful  action  of  the  blood  stream  in  the 
latter. 

Emboli  originating  in  the  left  heart  or  in  the  great  vessels  enter  the 
arterial  circulation  and  are  arrested  at  the  division  of  an  artery 
(riding  embolus),  or  become  impacted  where  the  lumen  of  the  vessel 
is  equal  to  the  diameter  of  the  embolus.     When  this  occurs  in  an. 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     1003 

artery  supplying  an  important  part,  there  is  not  time  for  the  estab- 
lishment of  collateral  circulation,  and  necrosis,  attended  with  a  stormy 
clinical  picture,  promptly  ensues.  Bacterial  embolism  produces 
arteritis  and  emholomycotic  aneurism. 

Venous  emholi  are  not  only  more  frequent,  but  also  more  dangerous 
than  the  arterial.  They  originate  from  the  thrombotic  areas  in  the 
large  and  small  veins  located  within  traumatized  or  infected  areas, 
reach  the  right  beart  and  are  carried  by  the  pulmonary  arteries  to 
the  lungs,  where  they  either  cause  death  from  circulatory  obstruction 
(which  is  preceded  by  great  dyspnea)  or,  when  only  a  smaller  vessel 
is  obstructed,  provoke  the  picture  of  hemorrhagic  infarct. 

In  rare  instances  an  embolus  may  pass  through  a  patent  foramen 
ovale  and  enter  the  general  circulation  (paradoxical  embolus),  or  an 
embolus  in  a  large  vein  may  be  carried  backward  (retrograde  embo- 
lus) when  the  right  heart  is  overdistended  and  the  entire  venous 
sj^stem  transmits  the  pulse  wave  (Ribbert*'). 

Infected  emboli  produce  metastatic  abscesses  in  the  lung.  When 
emboli  of  this  kind  originate  in  the  lung  (tuberculous  foci),  they 
often  lead  to  infarct  formed  areas  of  infection  in  various  portions  of 
the  body,  especialh-  in  situations  where  the  circulation  is  terminal 
(gut,  spleen,  bones,  etc.). 

The  diagnosis  of  thrombosis  can  only  be  made  when  large  vessels 
are  obstructed.  Chronic  edema  due  to  other  causes  is  not  easily 
excluded.  The  progressive  increase  in  pulse  rate,  supposed  to  be  an 
early  indication  of  the  condition,  would  seem  to  be  of  little  diagnostic 
value  (Kiister*^). 

The  treatment  consists  of  complete  rest,  immobilization ,  and  eleva- 
tion of  the  affected  part,  maintained  for  three  weeks  with  the  view  of 
favoring  fixation  of  the  thrombus  and  development  of  collateral  cir- 
culation. The  residual  edema  may  be  controlled  by  light  pressure 
bandages.  Massage  is  positively  contra-indicated.  The  use  of  warm 
baths  is  inadvisable.  The  ligature  of  thrombosed  veins  is  taken  up 
elsewhere  (PartX). 

In  embolism,  especially  in  the  dreaded  lung  embolism,  complete  rest 
is  the  best  measure  of  relief  and  may  prevent  extension  of  the  process. 
The  use  of  large  doses  of  morphia  is  justifiable.  Heart  stimulants 
should  be  given  cautiously,  as  increased  cardiac  activity  may  loosen 
additional  emboli.  Prompt  incision  of  an  obstructed  artery  and 
removal  of  the  embolus  and  repair  by  suture,  while  at  times  successful 


1004     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

(femoral  by  Ssabanejewsky ;"  pulmonary  by  Trendelenburg;*^  com- 
mon iliac  by  Murphy**^),  is  of  doubtful  utilit}'. 

Pulmonary  emhoUsm  and  a  fatal  outcome  is  a  constant  menace  in 
connection  with  acute  inflamniatory  processes  in  ike  pelvis,  pj'osalpinx, 
appendicitis,  etc.,  and  not  rarely  occurs  when  convalescence  has  been 
established  after  operative  efforts  at  relief. 

Lymphangiectasis. —  Lj-mphangiectasis  occurs  in  connection  with 
obstruction  of  the  thoracic  duct  and  its  larger  branches  from  pressure 
by  tumors,  etc.,  and  is  of  clinical  importance  when  the  lymph  vessels 
rupture  and  cause  chylous  effusion  into  the  thoracic  and  abdominal 
cavities  (chylous  ascites,  chjdothorax) . 

LympJiatic  varices  occur  in  the  skin  and  subcutaneous  tissues  after 
prolonged  or  repeated  attacks  of  inflammation,  which  cause  throm- 
bosis or  obliteration  of  the  lymph  channels  (habitual  erysipelas,  lymph- 
angitis, invasion  of  the  lymph  channels  by  filaria  sanguinis)  or  when 
the  vessel  walls  are  adherent  to  the  surrounding  tissues ;  and,  at  times, 
are  s:equential  to  extensive  extirpation  of  the  inguinal  glands.  They 
also  follow  extensive  cojitusinns  and  severe  phlegmonous  processes. 
Lymphangiectasis  often  merges  into  pachyderma. 

Dilatation  of  the  lymph  channels  of  the  skin  is  characterized  by  syni- 
metricol  sivelling,  which  is  studded  with  numerous  small  (rareh^  larger 
than  a  pea),  more  or  less  closely  apposed  vesicles  filled  with  a  clear  or 
milky  fluid.  Restricted  pressure  produces  pitting  (similar  to  that 
occurring  in  edema)  which  is  slowly  effaced  (lymphangiectasia 
reticularis). 

Dilatation  of  the  larger,  suhcutatieous  branches  is  manifested  by  the 
appearance  of  serpentine  strands  the  size  of  an  earthworm,  over  which 
the  skin  is  normal  or  covered  with  small  vesicles,  and  distended  with 
a  slightly  doughy  infiltrate.  ^Vhen  the  subfascial  IjTnphatics  are  also 
involved,  atrophy  of  the  intermediate  soft  parts  causes  the  affected 
zone  to  take  on  the  form  of  large  soft  tumors  {lymphangiectasia 
tuhercularis) . 

Lymphangiectatic  swelling  progresses  very  slowly,  but  may  be 
attended  with  periods  of  sudden  exacerbation  followed  by  return  to 
indolence. 

A  moderate  degree  of  lymphangiectasis  is  not  readily  differentiated 
from  lymphangioma ;  the  congenital  forms  would  seem  to  belong  to 
the  latter  class.  "When  the  dilated  hnnph  spaces  coalesce  the  micro- 
pcopic   picture   closely   resembles   the   cavernous   form.     The   bluish 


DISEASES  OF  THE  BLOOD  AND  LYMPH  VESSELS     1005 

shimmer  of  venous  blood  through  the  skin  in  phlehectasis  readily 
differentiates  it  from  the  condition  under  consideration. 

Lymphang'iectatic  skin  is  prone  to  inflammation  and,  when  broken, 
is  the  site  of  the  port  of  exit  in  lymphorrhea.  Slight  trauma  ruptures 
the  vesicles  and  is  often  followed  by  the  profuse  discharge  of  lymph. 
This  may  persist  for  weeks  and  montlis  and  is  attended  with  grave 
nutritional  disturbances.  The  discharging  area  is  particularly  liable 
to  infection  and  is  often  the  seat  of  erj'sipelas  and  plilegmonous  pro- 
cesses. The  occasional  appearance  of  chyle  in  the  fluid  is  explained 
by  the  existence  of  anastamosis  between  the  affected  part  and  the 
intestinal  plexus  (Albrecht*^). 

The  treatment,  in  cases  of  moderate  extent,  consists  of  excision  of 
the  obstructed  vessels.  More  extensive  areas  disappear  under  com- 
pression bandaging  and  elevation  of  the  part.  When  lymphorrhea  is 
present  the  part  must  be  protected  with  sterile  ointments  to  prevent 
maceration  and  infection  of  the  skin.  Fistulce  will  often  close  after 
cauterization  with  the  silver  stick.  In  obstinate  cases,  incision  and 
firm  tamponade  or  the  use  of  the  thermocautery  may  be  necessary. 

Dilatation  of  the  lymph  spaces  within  the  lymph  glands,  which 
occurs  most  frequently  in  connection  with  invasion  by  filariae  causes 
dilatation  of  contiguous  hTnph  vessels,  or  ma.y  be  secondary  to  it 
( Albrecht*' ) .  The  process  is  attended  with  the  gradual  disappearance 
of  the  glandular  parenchyma,  which  is  replaced  by  hollow  spaces  vary- 
ing in  size  and  lined  with  a  layer  of  endothelium.  The  zone  of  the 
affected  glands  (usually  the  groin)  is  covered  with  normal  or  lymph- 
angiectatic  skin,  is  soft  to  the  touch,  and  presents  a  moderate  degree 
of  symmetrical  or  nodular  swelling.  Foci  of  this  sort  are  readily 
infected  and,  as  can  be  seen  from  the  anatomical  picture,  are  especially 
likely  to  develop  a  serious  general  infection  {lymph-adenocele) . 

BIBLIOGRAPHY 

1.  Marchand.     21st  Kong.  f.  innere  Med.,  Leipzig,  1904. 

2.  Thoma.     Virehow's  Arch.  Bd.  104,  1886. 

3.  V.  Manteuppel.     Kocher's  Encj^l.,  1901. 

4.  Phaenomenow.     Same  as  No.  5. 

5.  Thoma.     Virehow's  Arch.  Bd.  111-11.3,  1888. 

6.  Eppinger.     Arch.  f.  klin.  Chir.  Bd.  35,  1887. 

7.  Thoma.     Virehow's  Arch.  Bd.  IIG,  1889. 

8.  V.  Bramann.     Arch.  f.  klin.  Chir.  Bd.  33,  1886. 

9.  Bevan.     Quoted  from  Tillmann,  Lexer-Bevan,  New  York,  1908. 

10.  V.  Bergmans.     Arch.  f.  klin.  Chir.  Bd.  69,  1903. 

11.  Delbet.     Trait,  d.  chir.  Le  Dentu  et  Delbet,  Paris,  1907. 


1006     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

12.  Franz.     Arch.  f.  klin.  Chir.  Bd.  75,  1905. 

13.  Matas.     Transact.  Amer.  Surg.  Assoc,  xx,  1902;    also  Jr.  Amer.  Med. 

Assoc,  1908;   also  Zentrbl.  f.  Chir.,  1907. 

14.  MOYNiHAN.     Anns,  of  Surg.,  1898. 

15.  Wolff.     Beitr.  z.  klin.  Chir.  Bd.  58,  1908. 

16.  TscHERNiACHOWSKY.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  123,  1913. 

17.  Murphy.     Med.  Record,  1897. 

18.  Lexer.     Chir.  Kong.  Vehr.,  1907,  ii,  and  1912,  i. 

19.  Gluck.     Quoted  by  Lexer,  Allg.  Chir.  ii,  Stuttgart,  1914. 

20.  Matas.     See  No.  13,  also  Anns,  of  Surg.,  1903,  and  Transact.  Amer. 

Surg.  Assoc,  1905. 

21.  Henle.     Zentrbl.  f .  Chir.,  1914. 

22.  V.  Frisch.     Arch,  f .  klin.  Chir.  Bd.  79,  1906 ;   also  Zentrbl.  f .  Chir.,  1914. 

23.  HOFMANN.     Beitr.  z.  klin.  Chir.  Bd.  24,  1899. 

24.  Lexer.     Same  as  No.  19. 

25.  Halsted.     Johns  Hopkins  Bull.,  1905 ;   Jr.  A.  M.  A.,  1906 ;   Jr.  Exper. 

Med.,  1909. 

26.  Sargo.     Zentrbl.  f.  Grenzgeb.,  1899. 

27.  Beck.     Same  as  No.  26. 

28.  Bass.     Zentrbl.  f.  Grenzgeb.,  1904. 

29.  LusK.     Anns,  of  Surg.,  1916  and  1917. 

30.  Lowenstein.     Mitteil  a.  d.  Grenzgeb.  Bd.  18,  1908. 

31.  Jouxanxe.     These  de  Paris,  1905. 

32.  V.  Rudiger-Rydygier.     Deutsch.  Zeitsch.  f.  Chir.  Bd.  91,  1908. 

33.  Madeluxg.     Quoted  by  F.  Fraenkel,  Beitr.  z.  klin.  Chir.  Bd.  36,  1902. 

34.  Hesse  and  Schaak.     Chir.  Kong.  Verb.,  1911,  ii. 

35.  Zahx.     Quoted  by  Ziegler,  Eulenberg's  Realencycl   (3d  ed.),  with  lit. 

36.  ASCHOFF.     Verb.  d.  Naturforsch,  1911,  and  Beitr.  z.  path.  Anat.  Bd.  52, 

1911. 

37.  BizzozERO,  Eberth,  Schimmelbush  and  others.    Same  as  No.  35. 

38.  DiETjEX.     Same  as  No.  35. 

39.  Dietrich.     In  Aschoff's  Allgem.  Path.  Anat.  Jena,  1909. 

40.  Alex.  Schmidt.     Same  as  No.  35. 

41.  Morawitz  and  Lossen.     Deutsch.  Arch.  f.  klin.  Med.  Bd.  94,  1908. 

42.  RiBBERT.     Deutsch.  med.  Woch.,  1914,  No.  2. 

43.  KiJSTER.     Zeitschr.  f.  Geburtshilfe,  ix,  1911. 

44.  SsABAXEjEWSKEY.     Hildcbraudt's  Jahresbericht,  1896. 

45.  Trexdelenberg.     Chir.  kong.  Verb.,  1908,  ii. 

46.  Murphy.     Jr.  A.  M.  A.,  Ixii,  1909. 

47.  Albrecht.    Deutsch.  Zeitschr.  f.  Chir.,  Bd.  86,  1907. 


CHAPTER  V 

THE  LIGATURE  OF  AETEEIES  IX   THEIR  CONTINUITY 

General  Considerations.  —  After  due  consideration  it  seems  best 
that  only  those  arteries,  the  ligature  of  which  is  of  surgical  import- 
ance, should  be  taken  up;  omitting  such  vessels  as  the  obturator,  the 
dorsalis  pedis,  the  internal  mammary,  and  not  a  few  others  which 
are  practicalh'  never  tied  in  their  continuity,  except  perhaps,  coinci- 
dent to  an  operation  in  the  course  of  which  they  are  exposed  and 
interfere  with  its  accomplishment.  It  has  also  seemed  justifiable  not 
to  encumber  this  work  with  extensive  anatomical  considerations,  nor 
with  a  recital  of  collateral  circulation,  both  of  which  are  so  readily 
available  in  works  devoted  to  anatomy  that  surely  form  a  part  of  the 
literarj'  equipment  of  every  student  and  practitioner. 

In  the  ligature  of  arteries  in  their  continuity,  six  guides  are  used, 
the  linear,  the  muscular,  the  hony,  the  contiguous  anofomical,  the 
pulsation,  and  the  color  of  the  vessel. 

The  linear  guide  is  a  line  drawn  on  the  surface  of  the  body  corre- 
sponding to  the  course  of  the  artery  beneath.  The  muscular  guide  is 
based  on  the  relation  which  the  vessel  bears  to  some  portion  of  a  well 
developed  superficial  or  deep  muscle.  The  contiguous  anatomical 
guide  includes  the  relation  the  vessel  bears  to  the  surrounding  parts ; 
this  may  be  a  muscle  or  hony  prominence  or  a  nerve.  The  pinkish 
color  of  an  artery  shimmering  through  its  sheath  is  very  character- 
istic, and  when  its  pulsation  is  clearly  palpable,  little  doubt  as  to  its 
identity  is  left. 

In  exposing  an  artery  for  the  purpose  of  ligating  it,  the  primary 
incision  is,  when  possible,  made  in  the  course  of  the  vessel,  with  its 
center  corresponding  to  the  point  where  the  ligature  is  to  be  applied. 
The  length  of  the  incision  varies  with  the  depth  of  the  vessel  ap- 
proached :  it  is  best  liberally  to  divide  the  tissues,  thus  gaining  space 
and  making  forcible  retraction  of  the  soft  parts  unnecessary.  When 
the  sheath  of  the  vessel  is  reached,  it  is  picked  up  with  the  tissue 
forceps  and  a  small  buttonhole  opening  is  made  in  it  with  the  scalpel. 

1007 


1008     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


The  ligature  is  then  passed  into  the  sheath  by  means  of  a  carrier  (Fig. 
491),  the  forceps  grasp  the  ligature,  which  is  drawn  out  on  the  distal 
side  of  the  artery,  and  the  carrier  is  withdrawn.  The  practice  of 
today  is  to  thread  the  ligature  upon  a  suitably  curved,  slender,  dull 
pointed  needle  (the  writer  employs  for  the  purpose  a  round,  curved 


Fig.  491. —  Right  and  Left  Aneurism  Needles. 


needle,  the  point  of  which  has  been  cut  otf  and  filed  smooth)  which 
is  passed  around  the  artery  by  means  of  an  ordinary  needle  holder 
in  the  manner  shown  in  Fig.  492 ;  the  needle,  or  improvised  carrier 
is  grasped  with  forceps,  and,  together  with  the  ligature   (single  or 


Fig.  492. —  Passing  the  Ligature  Around  the  Artery  with  a  Ligature  Needle 
BY  AIeans  of  a  Needle  Holder. 


double),  is  drawn  out  on  the  side  of  the  sheath  opposite  to  its  entrance. 
This  obviates  "fumbling"  for  the  ligature,  which  is  usually  more  or 
less  covered  with  blood,  and  is  never  as  accessible  as  the  end  of  the 
needle.  As  a  rule,  the  ligature  is  passed  away  from  vulnerahle  con- 
tiguous structures   (large  veins,  etc.).     Most  surgeons  use  silk   for 


LIGATURE  OF  ARTERIES  IN  THEIR  CONTINUITY     1009 


tying  arteries  as  large  or  larger  than  the  external  carotid ;  for  smaller 
ones,  catgut  may  be  used.  The  ligature  is  tied  by  a  reef  or  surgeon's 
knot.  Very  large  arteries,  such  as  the  subclavian  and  iliacs,  are 
better  tied  with  "floss  silk,"  the  ''stay  knot"  (which  originated  with 
Ballance  and  Edmunds^)  being  best  adapted  for  the  purpose.  Fig. 
493  shows  the  "stay  knot"  applied  to  a  large  vessel.  Its  employment 
has  contributed  much  to  the  success  of  ligature  of  large  arteries  (a 
perusal  of  the  literature  in  this  connection  is  quite  worth  while  —  see 
bibliography).  Beyond  the  aneurism  needles  and  the  carefully  selected 
ligature  material,  no  especial  instruments  are  required  for  the  ligature 
of  arteries  in  their  continuity. 

ligature  of  the  Abdominal  Aorta. —  Ligature  of  the  abdominal  aorta 
is  of  doubtful  utility.  The  vessel  is  easily  approached  through  an 
incision  (four  or  five  inches  in  length)  through  the  abdominal  wall, 

the  center  of  which  cor- 
responds to  a  point  slightly  to 
the  left  of  the  umbilicus  (Fig. 
494).  The  patient  is  placed 
in  the  Trendelenburg  posi- 
tion ;  the  intestines  are  held 
aside  by  means  of  abdominal 
pads;  the  vessel  is  recognized 
by  its  pulsation  ;  the  posterior 
peritoneum  over  the  artery  is 
picked  up  with  forceps  and 
carefully  "nicked,"  and  the 
opening  enlarged  with  scissors.  The  edges  of  the  divided  peri- 
toneum are  grasped  with  long  forcipressure  and  held  apart  by  an 
assistant,  and  the  ligature,  which  should  consist  of  strong  kangaroo 
tendon  or  of  ox  aorta,  is  passed  around  the  artery  away  from  the  vena 
cava.  Basing  our  conclusions  on  observations  made  in  connection  willi 
transperitoneal  ligature  of  the  common  and  internal  iliac  arteries,  the 
intent  should  be  easily  accomplished  through  an  ample  celiotomy 
incision  and  liberal  division  of  the  posterior  peritoneum.  The  ligature 
is  tied  with  a  "stay  knot"  (Fig.  493).  The  posterior  peritoneum  is 
sutured  with  catgut  and  the  celiotomy  wound  closed  in  the  usual 
manner  (Part  XVI). 

Jaeobson^  advises  placing  the  ligature  between  the  origin  of  the 
inferior  mesenteric  arterj-  and  the  bifurcation.  BrA^ant^  says  that,  of 
fourteen  reported  cases,  none  survived  for  longer  than  forty-eight 


Fig.  493. —  The  Ballakce  and  Edmund's 
Stay  Knot. 

4,  Single  fold.     B,   The  knot  completed. 


1010     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


hours.     The  establishment  of  collateral  circulation  is  proved  by  the 
postmortem  findings  in  connection  with  obliteration  of  the  artery  by 
disease,   and  by  experimental   observations    (Barnwell*   and  Kast^), 
There  is  now  no  reason  for  attempting  the  retroperitoneal  method  of 
approach,  though,  strange  to  say,  Monteiro®  reports  a  case  done  in  this 
way,  W'hich  survived  the  operation  for  ten  days.     The  employment  of 
temporary  compression  of  the  aorta  by  means  of  especially  devised 
instruments,  is  taken  up  in  extenso  by  Keen^  in  connection  with  a  case 
which     survived     the     pro- 
cedure for  fortj'-eight  days. 
Tillaux  and  Riche^  report  a 
case  in  w^hich  the  artery  was 
tied  by  the  transperitoneal 
method  and  the  patient  lived 
thirty-nine  days. 

Ligature  of  the  Iliac  Ar- 
teries.—  The  common  iliac 
arteries  have  been  tied  by 
the  transperitoneal  and  ex- 
traperitoneal methods.  The 
latter  (since  the  advent  of 
asepsis)  is  no  longer  prac- 
ticed. Its  technic  (ascribed 
to  Crampton,"  1818)  is  de- 
scribed in  the  older  text- 
books, among  which  Jacob- 
son  and  Stewart^  and  Fig.  494. 
Bryant^  may  be  advantage- 
ously consulted.  Kocher^° 
presents  a  remarkably  clear 
description  of  the  technic. 
In  either  event,  the  opera- 
tion is  followed  by  gangrene  of  the  foot  in  about  one  half  of  the  cases 
(Kocher^"). 

The  technic  of  the  transperitoneal  method  is  described  in  connection 
with  the  similar  method  of  ligating  the  other  iliac  arteries. 

The  external  and  internal  iliac  arteries  may  be  tied  also  by  the 
extraperitoneal  and  the  transperitoneal  methods.  For  the  former 
purpose  the  incision  alluded  to  in  connection  with  the  common  iliac 
arterj^  may  be  employed.     However,  in  recent  years  this  has  also  been 


Incisions    tor    Ligature   of    Ab- 
dominal Vessels. 

a,  Incision  for  ligature  of  abdominal  aorta; 

b,  incision   for  ligature   of  left  iliac   arteries; 

c,  incision  for  ligature  of  right  iliac  arteries; 

d,  incision  for  extraperitoneal  ligature   of  ex- 
ternal iliac  artery. 


LIGATURE  OF  ARTERIES  IN  TIIEIR  CONTINUITY     1011 

abandoned  in  favor  of  the  transperitoneal  approach.  The  authorities 
mentioned  above  may  be  consulted  in  this  connection  (see  bibliography, 
nos.  2,  3,  and  10). 

The  Transperitoxeal  Method  of  Ligating  the  Iliac  Arteries. — 
The  right  common  iliac  artery  is  approached  through  a  celiotomy 
incision  (p.  1010),  beginning  one  inch  to  the  right  of  and  on  a  level 
with  the  umbilicus  and  extending  downward  four  or  five  inches  (Fig. 
494c).     After  the  peritoneum  is  opened  the  patient  is  placed  in  the 


Fig.  495. —  Transperitoxeal  Ligature  of  the  Eight  Common'  Iliac   Aetebt. 


The  patient  is  in  the  Trendelenberjj  position.  The  wound  is  held  open  with  a 
self  retaining  retractor.  The  posterior  pritoneum  is  opened  and  the  ligature  is 
being  passed  around  the  vessel  at  its  middle. 


Trendelenburg  position;  the  intestines  are  held  aside  with  pads;  the 
pasterior  peritoneum  is  lifted  with  forceps  and  carefully  nicked  at  a 
point  opposite  the  center  of  the  celiotomy  incision,  and  the  opening 
enlarged,  to  the  extent  of  about  two  inches,  with  scissors.  The  ureter 
crosses  the  arterj^  at  the  bifurcation,  but,  as  it  is  attached  to  the  under 
surface  of  the  peritoneum,  it  is  readil}'  displaced  with  it  as  the  open- 
ing is  enlarged.  The  artery  is  now  exposed  to  view,  the  vein  lying 
to  its   outer  side  and  behind.     The   ligature   carrier   is   introduced 


1012     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

between  the  artery  and  vein,  is  grasped  on  the  inner  side  of  the  former 
(Fig.  495)  and  the  ligature  "dragged"  after  it.  The  ligature  should 
consist  of  floss  silk  and  should  be  tied  in  a  "stay  knot"  (Fig.  493). 
The  opening  in  the  posterior  peritoneum  is  closed  with  catgut  and  the 
celiotomy  wound  sutured  (Part  XVI). 

Transperitoneal  ligature  of  the  left  common  iliac  artery  is  accom- 
plished through  an  incision  two  inches  to  the  left  side  and  on  a  level 
with  the  umbilicus  and  extending  downward  four  or  five  inches  (Fig. 
494b).  The  section  of  the  abdominal  wall,  posture  of  the  patient, 
and  opening  of  the  peritoneum  is  accomplished  in  precisely  the  same 
manner  described  in  connection  with  the  right  common  iliac  artery 
(see  above).  However,  as  the  vein  lies  to  the  inner  side  (although 
the  ligature  is  passed  between  them),  the  carrier  is  directed  outward. 
In  the  additional  steps,  the  operation  does  not  differ  from  those 
already  described. 

The  right  external  and  internal  iliac  arteries  may  be  ligated  through 
the  incision  employed  for  the  purpose  of  exposing  the  common  iliac 
on  that  side  (Fig.  494c)  ;  and  the  left  external  and  internal  iliac 
arteries  may  be  ligated  through  the  incision  described  in  connection 
with  ligature  of  the  common  iliac  on  that  side  (Fig.  494).  In  either 
instance,  it  is  only  necessary,  after  the  posterior  peritoneum  is  opened, 
to  locate  the  bifurcation  of  the  common  iliac  and  to  pass  the  ligature 
accordingly. 

Transperitoneal  ligature  of  the  iliac  arteries  was  given  its  initial 
impetus  by  Dennis,^^  who,  however,  devoted  his  energies  largely  to 
the  internal  branches.  At  this  time  it  is  inconceivable  that  other 
than  the  transperitoneal  route  should  be  considered,  except,  perhaps, 
for  ligature  of  the  external  iliac  just  above  Poupart's  ligament  (see 
below).  As  a  matter  of  fact,  any  of  the  iliac  arteries  is  readily 
ligated  through  an  ample  median  celiotomy  wound.  The  writer  has 
(in  the  last  fifteen  years)  simultaneously  deligated  both  internal  iliac 
arteries,  as  a  preliminary  step  in  panhysterectomy,  fourteen  times, 
emplojnng  a  median  celiotomy  incision  for  the  purpose;  and  has  tied 
the  right  common  iliac  artery,  through  the  incision  described  above, 
four  times.  In  none  of  the  cases  was  the  technic  attended  with  diffi- 
culty. Jacobson  and  Steward-  devote  considerable  space  to  the  dis- 
cussion of  the  extraperitoneal  methods  (see  bibliography). 

Ligature  of  the  external  iliac  artery  above  Po^ipart's  ligament  is 
accomplished  without  opening  the  peritoneum.  The  course  of  the 
artery  corresponds  to  a  line  drawn  from  the  left  side  of  the  umbilicus 


LIGATURE  OF  ARTERIES  IN  THEIR  CONTINUITY     1013 


to  the  middle  of  Poupart's  ligament.  The  incision  of  approach  is 
slightly  curved  (concavity  downward)  ;  it  begins  about  one  inch 
above  Poupart's  ligament  and  immediately  outside  the  external 
abdominal  ring,  and  termmates  on  a  level  with  and  two  inches  internal 
to  the  anterior  superior  spinous  process  of  the  ilium  (Fig;  494d). 
The  skin,  superficial  fascia,  and  aponeurosis  of  the  external  oblique 
are  sectioned,   the  fibers  of  the  internal   oblique   and  transversalis 

muscles  are  separated,  the  fascia  of  the 
transversalis  is  picked  up  with  tissue 
forceps  and  opened  to  the  full  extent  of 
the  wound.  The  peritoneum  and  its  sub- 
serous tissue  are  pushed  upward;  the 
inner  border  of  the  psoas  magnus  is 
located,  and  the  vessel  is  felt  pulsating  at 
the  inner  margin  of  this  muscle.  The 
areolar  tissue  surrounding  the  artery  is 
-B  opened  and  the  carrier  passed  between 
the  artery  and  the  vein  from  within  out- 
ward. After  the  vessel  is  tied,  the  various 
divided  deeper  layers  are  sutured  sep- 
arately with  catgut  and  the  superficial 
wound  is  closed  with  interrupted  silk- 
worm gut  sutures.  The  artery  is  often  a 
"close  neighbor"  in  the  Bassini  operation 
for  the  relief  of  hernia  (Part  XVI,  chap. 
xii). 

Ligation  of  the  Femoral  Arteries. —  The 

Fig.  496.— Incision  for  Liga-   course  of  the  femoral  artery  corresponds 

TURE      OP     THE      FEMORAi  fo    a    Hnc    drawu    from   the    middle    of 

Artery     (A)     below     Pou-   _,  ,  ,     ■,■  ...-,•.  -, 

part's   Ligament-    (B)    at  Poupart  s  ligament  to  the  internal   con- 

THE  Apex  of  ScAkpA's  Tri-   dyle  of  the  femur,  with  the  thigh  abducted 
angle;     (C)     in    Hunter's  t^  •    .•    i   •      .t, 

CANAii.  and  rotated  outward.     It  is  tied  m  three 

situations;  just  below  Poupart's  liga- 
ment,   at   the   apex   of   Scarpa's  triangle,    and   in   Hunter's    canal. 

The  common  femoral  heloiv  Poupart's  ligament  is  ligated  in  connec- 
tion with  disarticulation  through  the  hip  joint  (p.  905).  For  control 
of  the  circulation  in  the  limb,  it  is  best  to  tie  the  external  iliac. 

The  incision  of  approach  begins  just  below  the  middle  of  Poupart's 
ligament  and  extends  downward  in  the  course  of  the  vessel  for  a  dis- 
tance of  about  three  inches    (Fig.  496).     The  skin  and  fascia  are 


1014    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


careful!}'  divided,   and  the  pinkish,  white,   glistening  sheath  of   the 
vessels  comes  into  view.     This  is  picked  up  with  tissue  forceps  and 
cautiously  opened.     The  vein  is  visible  to  the  inner  side ;    the  nerve 
lies  to  the  outer  side 
of    the    artery    (Fig. 
497)  ;   the   carrier   is 
passed    between    the 
vein  and  artery,  the 
nerve  being  held  aside 
with  tissue  forceps  so 
that    it   may   not   be 
included    in   the    en- 
circling grasp  of  the 
ligature. 

In  li gating  the 
superficial  femoral  at 
the  apex  of  Scarpa's 
triangle  the  incision 
of  approach  (three 
inches  in  length)  is 
made  in  the  line  of 
the  course  of  the  ves- 
sel, its  center  cor- 
responding to  the 
junction  of  the  middle 
and  upper  thirds  of 
the  thigh,  in  the 
groove  at  the  inner 
aspect  of  the  sartorius 
muscle  (Fig.  496B) 
After  the  subcutane- 
ous tissue  is  divided, 
the  somewhat  delicate 
deep  fascia  becomes 
visible,  and  this  is 
also  opened  to  the  full 
extent  of  the  incision,  uncovering  the  inner  edge  of  the  sartoriuS 
muscle,  which  is  recognized  b}'  the  direction  of  its  fibers  (down- 
ward and  inward)  j  these  are  drawn  outward  (Fig.  497),  bringing 


Fig.  497. —  The  Femoral  Artery  Exposed  just 
BELOW  Poupart's  Ligament  and  at  the  Apex 
OF  Scarpa's  Triangle. 

In  the  latter  situation  the  sartorius  muscle  (S) 
is  drawn  outward ;  the  deep  fascia  (F)  is  split. 


LIGATURE  OF  ARTERIES  IN  THEIR  CONTINUITY    1015 


into  view  the  tense  deep  layer  of  the  fascia  lata.  The  latter  is  also 
opened,  exposing  the  vessel  with  its  accompanying  vein,  which  lies 
beneath  and  to  its  inner  side  (Fig.  497).  The  common  sheath  is 
opened;  the  vein  is  separated  by  blunt  dissection,  and  the  carrier 
insinuated  between  it  and  the  artery  and  the  latter  tied  with  silk  or 
kangaroo  tendon  (the  latter  is  preferable,  though  care  must  be  taken 

to  tie  a  "close 
knot").  The  wound 
(like  all  skin 
wounds)  is  best 
closed  with  inter- 
rupted silkworm  gut 
sutures  and  is  not 
drained. 

In  Hunter's  canal 
the  femoral  artery 
is  approached 
through  a  three  inch 
incision  made  at  the 
junction  of  the  lower 
and  middle  thirds  of 
the  thigh  on  a  line 
drawn  from  the 
anterior  superior 
spine  of  the  ilium  to 
the  internal  condyle 
(Fig.  496C),  expos- 
ing the  outer  side  of 
the  sartorius  muscle 
and  the  vastus  in- 
ternus.  The  white 
glistening  fibers  of 
the  line  between  the  adductor  magnus  and  the  vastus  internus, 
forming  the  roof  of  the  canal,  are  exposed,  and  when  this  layer  is 
opened  the  artery  comes  into  A'iew.  The  vein  lies  beneath  the  latter  and 
is  closely  associated  with  it  by  bands  of  connective  tissue  (Fig.  498). 
The  sheath  is  opened ;  the  vein  and  artery  are  carefully  separated 
and  the  carrier  passed  between  them.  The  artery  is  tied  with  silk  or 
Jiangaroo  tendon.  The  wound  is  closed  (without  drainage)  by  means 
of  three  silkworm  gut  sutures. 


Fig.  498. —  Exposure  of  the  Femoral  Artery  in 
Hunter's  Canal. 

A,  Vastus  externus;     B,  sartorius.      The  roof  of  the 
canal  (CC)   is  opened,  showing  the  artery. 


1016     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


The  popliteal  artery  should  uot  be  tied  in  its  continuity.  A  descrip- 
tion of  the  technic  is,  therefore,  omitted  (see  Bryant,^  Jacobson,^ 
Kocher,^"  Zuckerkandl^-). 

Ligation  of  the  Tibial  Arteries. —  The  anterior  tibial  artery  is  tied  in 
the  middle  sector  of  the  leg  by  making  a  three  inch  incision  on  a  line 
drawn  from  the  inner  (central)  edge  of  the  fibula  to  midway  between 
the  maUeoli;  this  is  about  a  finger's  breadth  external  to  the  crest  of 
the  tibia.  The  incision  is  carried 
through  the  dense  fascia,  exposing 
the  septum  between  the  tibialis 
anticus  and  the  extensor  pollicis 
longus  muscles.  Separation  of  these 
muscles  makes  the  anterior  surface 
of  the  interosseous  membrane  acces- 
sible. Before  the  vessels  are  reached 
the  deep  peroneal  nerve  is  encoun- 
tered; when  this  is  (gently)  pushed 
aside,  the  artery,  surrounded  by  its 
attendant  veins,  is  exposed  (Fig. 
499).  The  septum  between  the 
muscles  must  he  found;  failure  to  do 
this  leads  the  operator  astray.  The 
nerve  is  held  aside;  the  carrier  is 
insinuated  between  the  veins,  and 
■  the  ligature,  which  may  consist  of 
catgut,  is  tied.  The  wound  is  closed,  Fig.  499. —  Exposure  of  the  An- 
without  drainage,  by  means  of  three  ^^^^°^  ^^^^^^.  ^^''^^^- 

•■,■,                     ,        ,  The     fascia     is     divided     and     the 

SliKWOrm  gut  sutures.                           ^  tibialis    amicus    muscle    (A)    on    the 

"Willie  the  course  of  the  posterior  inner   side   and   the   extensor   hallueis 

,.,  .   7         ,                                 -,      ,            T  muscle    (B)    on    the    outer    side    are 

tibial   artery    corresponds   to    a   line  geparated.     In  the  space  thus  exposed 

drawn     from     the     middle     of     the    the  deep  peroneal  nerve    (C)    is  seen 
T.      ^  .      ^1       •    J.  1  1      resting  on  the  arterv,  surrounded  by 

popliteal  space  to  the  internal  mal-   j^s  accompanying  veins. 

leolus,    the    vessel    is    approached 

through  an  incision  located  at   the  inner  aspect   of  the   leg,   veri/ 

remote   from   the   linear  guide.      The   incision   of   approach    (three 

inches  in   length)    is  made  at  the  inner  side  of  the  middle  third 

of  the  leg,   a  finger's  breadth  behind  the  posterior  border  of  the 

tibia  (Fig.  500).     The  skin  and  fascia  are  divided;  the  fibers  of  the 

soleus  are  detached  from  the  posterior  surface  of  the  tibia,  exposing 


LIGATURE  OF  ARTERIES  IN  THEIR  CONTINUITY     1017 


the  superficial  and  deep  groups  of  muscles  of  the  calf.  As  these  are 
pulled  sharply  backward,  the  deep  fascia  overlying  the  vessel  comes 
into  view,  beneath  which  the  artery,  accompanied  by  several  veins, 
and  the  posterior  tibial  nerve  are  visible.     The  fascia  is  picked  up  and 

opened ;  the  carrier  causes  the 
ligature  to  encircle  the  artery, 
care  being  taken  to  avoid  in- 
jury to  or  inclusion  of  the 
nerve.  The  wound  is  closed 
(without  drainage)  with  three 
silkworm  gut  sutures. 

Ligature  of  the  Innominate 
Artery. —  Ligature  of  the  in- 
nominate artery  presents  a 
problem  of  considerable  magni- 
tude. It  was  first  accomplished 
by  Valentine  Mott^^  in  1818; 
the  patient  survived  the  opera- 
tion only  a  few  days.  In 
1859  an  American  surgeon 
(Cooper^*)  resected  the  upper 
portion  of  the  sternum  and  the 
sternal  end  of  the  clavicle  in 
order  to  reach  the  artery;  this 
patient  lived  nine  days.  In 
1865,  Smyth^^  of  New  Orleans 
reported  the  first  successful 
ease;  in  1889,  Lewtas,"  an 
English  surgeon  serving  in 
India,  tied  the  vessel  for  the 
relief  of  a  traumatic  aneurism 
of  the  subclavian  ;  this  was  the 
second  case  that  recovered.  The 
next  reported  success  is  that  of 
Coppinger"  (1893)  ;  the  next 
two  are  reported  by  S.ATnonds^^ 
and  BurrelP^  respectively.  From  then  on  the  number  of  successful  cases 
increased  rapidly.  This  is  attributed,  in  part,  to  the  employment  of 
asepsis  and,  in  part,  to  the  use  of  the  method  of  ligating  evolved  by 
Ballance  and  Edmunds.^ 


Fig.  500. — -Exposure  of  the  Posterioh 
Tibial  Artery  in  the  Middle  Third 
OF  THE  Leg. 

The  origin  of  the  soleus  muscle  (A) 
is  cut  away  from  tlie  tibia.  The  muscu- 
lature of  the  calf  is  drawn  backward. 
The  artery  (B),  accompanied  by  two 
veins,  is  visible.  The  nerve  (C)  lies  be- 
side the  vessels. 


1018     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

The  technic  employed  in  most  of  the  cases  (except  those  of  Cooper^* 
and  of  BurrelP")  was  in  all  essential  regards  the  same  as  that  of 
Mott/3 

The  course  of  the  vessel  corresponds  to  a  line  drawn  from  the  middle 
of  the  junction  of  the  first  and  second  bones  of  the  sternum  to  the 
right  sternoclavicular  articulation. 

As  the  movements  of  the  chest,  trachea  and  muscles  of  the  neck 
incidental  to  respiration  interfere  with  the  accuracy  of  the  manipula- 
tions, intratracheal  narcosis  is  desirable.  The  patient  is  postured 
with  the  neck  extended  (as  for  thyroidectomy,  etc.)  and  the  head 
turned  toward  the  left  shoulder.     An  incision  is  made  three  inches  in 


Fig.  501. —  Incisions  for  Ligature  of  Thorax  and  Neck  Vessels. 

A,  Mott's  incision  for  ligature  of  the  innominate  artery;  B,  incision  for 
splitting  the  manubrium  for  ligature  of  innominate  artery  (Bardenheuer)  ;  C, 
Coughlin's  incision  for  resection  of  the  manubrium  preliminary  to  ligature  of  the 
innominate  artery;  D,  atypical  incision  for  ligature  of  the  first  portion  of  the 
subclavian  artery;  E,  incision  for  ligature  of  the  third  portion  of  the  subclavian 
artery;  F,  incision  for  ligature  of  the  common  carotid  artery;  G,  incision  for 
ligature  of  the  external  and  internal  carotid  arteries;  H,  incision  for  ligature  of 
the  lingual  artery;  1,  incision  for  exposure  of  first  portion  of  the  axillary  artery. 


length,  extending  along  the  upper  border  of  the  clavicle  to  a  point 
opposite  the  center  of  the  episternal  notch.  This  is  joined  by  another 
of  similar  length  along  the  anterior  portion  of  the  sternomastoid 
muscle  (Fig.  501A).  The  triangular  flap  thus  outlined,  consisting  of 
skin,  superficial  fascia,  and  plat3^sma,  is  turned  upward  and  outward. 
The  sternal  and  clavicular  portions  of  the  sternomastoid,  sternohyoid 
and  sternothj-roid  muscles  corresponding  to  the  horizontal  incision 
are  separated  from  their  bony  attachments  and  turned  aside  (out- 
ward). The  inferior  thyroid  veins  are  drawn  aside  or  may  be  divided 
between  two  ligatures.  The  deep  cervical  fascia  is  cautiously,  but 
widely,  opened,  bringing  into  view  the  sheath  containing  the  common 


LIGATUKE  OF  ARTERIES  IX  THEIR  COXTINXITY     1019 

carotid  artery,  pneumogastric  nerve  and  the  internal  jugular  vein. 
The  sheath  is  opened  and  the  vein  and  nerve  are  drawn  to  the  outer 
side  or,  which  astonishingly  facilitates  the  subsequent  steps  of  the 
operation,  the  vein  is  divided  between  two  ligatures  and  the  lower 
portion  turned  downward;  the  common  carotid  artery  is  followed 
downward  to  the  origin  of  the  subclavian.  The  upper  portion  of  the 
innominate  is  then  separated  from  its  attachments  by  the  fingers; 
the  subclavian  vein,  together  w^ith  the  stump  of  the  internal  jugular, 
is  depressed  and  the  carrier  caused  to  encircle  the  artery  from  below 
upward  and  from  behind  in  close  contact  with  the  vessel.  The  liga- 
ture, which  should  consist  of  silk,  should  be  applied  and  tied  in  the 
manner  advised  by  Ballance  and  Edmunds  (p.  1009). 

As  already  stated,  Cooper^*  (1859),  finding  the  field  of  exposure 
insufficient  for  the  purpose,  resected  the  sternoclavicular  articulation 
ami  the  upper  end  of  the  sternum-,  using  bone  cutting  forceps  for  the 
purpose,  thus  obtainmg  better  access  to  the  vessel.  In  1885,  Barden- 
heuer-°  practiced  a  similar  method  in  connection  with  removal  of  a 
tumor  encroaching  upon  the  mediastinum ;  this  suggested  to  him  the 
feasibility  of  gaining  access  to  the  innominate  in  a  similar  manner  for 
the  purpose  of  its  ligature ;  however,  the  method  was  not  successfully 
executed  until  1895  (by  BurrelP"  of  Boston).  Burrell  gives  a  detailed 
account  of  the  procedure ;  this  is  repeated  verbatim  br  Bryant.^ 

The  incisions  are  similar  to  those  already  described  (Fig.  501A). 
The  soft  parts  are  also  di"vnded  in  the  same  way;  the  sternal  end  of 
the  clavicle  and  the  upper  edge  of  the  sternum  are  removed  with  the 
rongeur,  a  flat  metal  retractor  being  slid  behind  the  bones  to  protect 
the  subjacent  parts;  the  sheath  of  the  carotid  is  opened  as  .stated 
above,  and  the  ligature  passed  and  tied  in  the  same  manner.  BurrelP^ 
used  two  silk  ligatures:  the  first  one  he  tightened  very  gradually 
(three  minutes  being  occupied  in  obliterating  the  lumen),  and  the 
second  one  was  pa.ssed  separately.  He  "felt  the  coats  of  the  vessel 
give  way"  when  the  first  knot  was  tightened.  This,  in  the  light  of  the 
evidence  submitted  b}'  Ballance  and  Edmunds,^  should  not  be  done, 
the  ligatures  being  tied  only  tight  enough  to  appose  the  inner  coats  of 
the  vessel. 

The  divided  muscles  are  approximated  by  buried  chromic  gut 
sutures  (drainage  is  not  employed)  and  the  .skin  closed  with  inter- 
rupted silkworm  gut  sutures.  The  space  between  the  sutures  gives 
ample  opportunity  for  the  escape  of  "ooze." 

The  after  treatment  is  taken  up  below. 


1020     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMOHS 


Sequential  to  Bardenheuer's  conception  and  the  successful  effort  of 
BurrelP**  (except  for  the  case  of  Moynihan,-^  1898,  who  seemed  to 
gain  satisfactory  access  to  the  artery  by  simply  turning  up  the  sternal 
end  of  the  clavicle),  Curtis^-  who,  like  most  surgeons,  felt  that  neither 
the  approach  of  Mott^^  nor  resection  of  the  bones  as  described,  afforded 
sufficient  room  for  the  exposure  of  the  artery  in  a  case  of  large  sub- 
clavian aneurism,  split  the  manubrium  through  the  vertical  incision 
of  Bardenheuer  (Fig.  501B).  The  steps  of  the  operation  are  fully 
described  in  the  original  article;    in  addition  to  this,  the  technic  is 


Fig.  502. 


Innominate  Artery  Exposed  by  Resection  of  the  Manubrium. 
Note  the  gland  lying  close  to  the  vein. 


completely  described  by  Bryant.^  Beyond  splitting  the  manubrium, 
Curtis^'  separated  the  halves  of  the.  sectioned  bone  with  a  broad 
retractor;  the  subsequent  steps  of  the  operation  are  similar  to  those 
employed  by  Coughlin,^^  which  are  described  immediately  below.  The 
latter  method  may  be  regarded  as  the  logical  outcome  of  the  applica- 
tion to  the  situation  of  the  lessons  learned  in  connection  with  the 
modern  surgery  of  the  thorax  (Part  XV) . 


LIGATURE  OF  ARTEEIES  IN  THEIR  CONTINUITY     1021 


The  head  of  the  patieut  is  extended ;  the  chin  turned  toward  the 
opposite  shoulder;  intratracheal  ether  narcosis  is  employed.  A  ver- 
tical incision  is  made  in  the  median  line  from  the  center  of  a  point 
level  with  the  upper  margins  of  the  clavicles,  downward  four  inches ; 
a  transverse  incision,  at  the  upper  end  of  the  first,  extends  one  and 
one  half  inches  to  either  side  of  the  median  line,  and  a  third  transverse 
incision  of  the  same  length  is  made,  its  center  corresponding  to  the 


Fig.  503. —  Atypical  Method  of  LiGATrRE  of  the  First  Portion  of  the 
Subclavian  Artery. 

A,  subclavaan  artery;  B,  sternomastoid  muscle  (divided);  C,  sternothyroid 
muscle;  D,  internal  jugular  vein  (divided)  ;  E,  omohyoid  muscle  (drawn  upward)  ; 
F,  vertebral  artery;  G,  thyroid  axis. 

lower  termination  of  the  vertical  one  (Fig.  501C).  The  two  flaps 
thus  outlined,  consisting  of  all  the  tissues  (including  the  periosteum  of 
the  manubrium),  are  reflected  outward,  exposing  the  sternoclavicular 
articulations,  the  sternum,  and  the  costal  cartilages  of  the  first,  second 
and  third  ribs.  The  perichondrium  of  the  costal  cartilages  is  opened 
transversely  and  the  cartilages  divided  with  bone  forceps.  The  sternal 
portion  of  the  sternomastoid  muscles,  the  anterior  sternal  clavicular 


1022     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


ligaments  and  the  iuterarticular  fibrocartilages  are  divided  close  to 

the  clavicle.     The  muscles  and  fascia  in  the  intercostal  spaces  and  the 

perichondrium  of  the  divided  costal  cartilages  are  separated  from  the 

edges  of  the  sternum.     A  flat,  thin,  blunt  ended  spatula  is  passed 

across  behind  the  sternum  at  the  level  of  the  third  cartilage  and  the 

sternum  divided  transversely  with  a  thin  bladed  rib  cutter. 

The  lower  end  of  the  upper  fragment  of  the  sternum  is  raised  and 

the  retrosternal  tissues  separated  from  its  under  surface  from  below 

upward,    keeping 

close    to    the    bone. 

At  the  upper  end  of 

the    fragment,    the 

sternothyroid    and 

hyoid    muscles    and 

the  posterior  sterno- 
clavicular ligaments 

are  divided  and  the 

loosened  portion   of 

the  sternum   re- 

moved.     Now,     a 

median    incision    is 

cautiously  made 

through    the    retro- 
sternal fascia  from 

above    downward ; 

the  left  innominate 

vein   comes   into 

view;  this  is  drawn 

downward   exposing 

the    sheath    of    the 

a  r  t  e  r  3'    which    is 

opened  for  about  one 
inch.  The  artery  is  encircled  with  the  ligature,  which-  is  tied  with  a 
stay  knot ;  the  retrosternal  fascia  is  closed  with  catgut  and  the  super- 
ficial flaps  are  apposed  with  interrupted  silkworm  gut  sutures. 
Coughlin^^  states  that  ultimately  there  is  no  appreciable  interfer- 
ence with  the  function  of  the  arms.  Coughlin-^  did  not  entirel}^ 
©■bliterate  the  vessel  at  the  primary  operation ;  instead,  he  almost 
occluded  it  with  an  aluminum  band,  closed  the  wound  and  three 


Fig.  504. —  Structures  Concerned  in  Ligature  op  the 
Third   Portion    of   the   Subclavian   Artery. 

A,  sternomastoid  muscle;  B,  scalenus  anticus  muscle; 
C,  scalenus  medius  muscle.  The  brachial  plexus  (-D) 
lies  to  the  outer  side  of  the  artery. 


LIGATURE  OF  ARTERIES  IX  THEIR  CONTINUITY     1023 


weeks  later  (under  local  anesthesia)  reopened  tlie  wound,  tied  the 
artery  just  distal  to  the  band  and,  at  the  same  sitting,  tied  the  right 
common  carotid  artery  just  below  its  bifurcation.  His  case  (a 
syphilitic  aneurism  of  the  right  subclavian  artery)  made  a  com- 
plete recovery ;  a  brilliant  achievement !  Doyen,-*  in  connection  with 
operations  on  the  mediastinum,  employs  a  technic  which  gives  ready 
access  to  the  artery.  He  uses  a  single  vertical  incision  and  resects  the 
manubrium  in  much  the  same  way  as  Couglilin,^^  except  for  the 
instruments  used,  which  are  especially  adapted  to  the  purpose. 
Irrespective  of  the  operative  method,  the  after  treatment  is  directed 


OMO-HYOID    M. 

'*        JU3UL  AR     V. 


,^:  ^COMMUNICANS. 
'^y''^\HYP0-GL05i,l  N 


EXT  CAROTID  A.iZ'). 


■EXT.  CAROTID    A.{\\. 


-sterno-thyoid  m, 
sterno-hyoid 
Fig.  505. —  Exposure  of  the   Common   Carotid   Artery. 


toward  keeping  the  patient  quiet.  This  relates  especially  to  coughing, 
which  is  not  a  little  enhanced  by  the  irritation  sequential  to  intra- 
tracheal narcosis.  For  the  purpose,  morphia  must  be  administered  in 
liberal  doses.  The  patient  is  caused  to  inhale  moist  air  and  is  nour- 
ished by  the  rectum  for  several  days  after  the  operation. 

Ligation  of  the  Subclavian  Arteries. —  On  the  left  side  the  subclavian 
artery  arises  from  the  arch  of  the  aorta  and  is,  therefore,  still  less 
accessible  than  the  right.  "With  the  neck  extended  and  the  chin 
turned  toward  the  opposite  shoulder,  the  artery  is  approached  through 
the  same  incisions  descrihed  in  connection  ivitli  those  of  Mott  in 
exposure  of  the  innominate  (on  the  right  side)  (Fig.  501A).    The  flap, 


1024     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

consisting  of  the  integument,  superficial  fascia  and  plat^^sma,  is 
turned  aside;  one  half  the  clavicular  and  the  entire  sternal  portion 
of  the  sternomastoid  muscles  are  divided  close  to  the  bones,  exposing 
the  sternohyoid  and  sternothyroid  muscles,  and  to  the  outer  side  the 
omohyoid.  The  sternohA'oid  and  sternothyroid  muscles  are  also 
divided  after  being  liberated  from  their  inclosing  fascia.  The  inner 
edge  of  the  scalenus  anticus  muscle  is  now  sought  for,  and  this  is 
followed  down  to  the  vessel  which  lies  behind  it.  The  structures  lying 
behind  the  artery  are  drawn  inward  and  the  carrier  is  insinuated 
between  the  vein  and  the  artery  and  made  to  precede  the  ligature 
around  the  artery  from  before  backward.     The  ligature  is  lied  with 


Fig.  506. —  ExposiTiE  of  the  External  Cagotid  Artery. 


a  stay  knot,  and  the  wound  closed  (without  drainage)  with  interrupted 
silkworm  gut  sutures.  It  should  be  feasible  to  tie  the  artery  in  the 
manner  described  in  connection  with  the  first  portion  of  the  right 
subclavian. 

The  first  portion  of  the  right  subclavian  arteru  (on  this  side,  a 
branch  of  the  innominate)  may  be  approached  in  precisely  the  same 
manner  as  is  described  in  connection  with  the  similar  operation  on  the 
left  side.  The  artery  is  reached  with  less  difficulty  in  this  situation. 
As  already  stated  in  connection  with  amputations  (p.  861)  and,  as  is 
apparent  from  the  discussion  entered  into  with  regard  to  resection  of 
the  manubrium  in  order  to  ligate  the  innominate  arterj^,  modern  sur- 


LIGATURE  OF  ARTERIES  IN  THEIR  CONTINUITY    1025 


gery  tends  to  deviate  from  prescribed  methods  of  procedure  and  to 
employ  those  best  suited  to  the  individual  problem.  In  accord  with 
this  notion,  the  writer  has,  on  two  occasions,  found  it  feasible  to  tie 
the  first  portion  of  the  subclavian  on  the  right  side  in  the  following 
way: 

Intratracheal  ether  narcosis ;    the  head  extended ;    the  chin  turned 
to  the  left  side;    the  shoulder  depressed.     The  incision  begins  at  the 

junction  of  the  outer 
and  middle  thirds  of 
the  clavicle,  is  car- 
ried in  a  full  curve 
upward  to  a  point 
two  inches  above  the 
clavicle,  and  then 
curves  downward  to 
terminate  over  the 
left  sternoclavicular 
articulation  (Fig. 
501D).  The  external 
jugular  is  tied  be- 
tween the  two  liga- 
tures; the  flap,  con- 
sisting of  skin, 
fascia,  and  pla- 
tysma,  is  turned 
down;  a  blunt  in- 
strument is  passed 
under  the  sicrno- 
mastoid  muscle 
from  its  inner  side 
and  the  muscle  is 
divided  one  and  one 
half  inches  above 
the  clavicle  and 
turned  down  over 
the  flap.  The  sterno- 
hyoid and  sternothyroid  muscles  are  drawn  toward  the  median  line; 
the  carotid  sheath  is  opened  verticall}' ;  the  internal  jugular  vein  is  iso- 
lated and  divided  between  two  ligatures ;  the  lower  stump  of  the  vein 
is  gently  dissociated  from  its  surroundings  and  followed  downward  to 


Fig.  507. —  Exposure  of  the  Lingual  Artery. 

The  gland  (A)  is  lifted  from  its  bed,  exposiiif^  the 
lingual  triangle.  The  latter  is  bounded  by  the  tendon 
of  the  digastric  muscde  (-B),  by  the  lateral  edge  of  the 
mylohyoid  (C),  and  by  the  hypoglossal  nerve  (D).  Its 
bottom  is  filled  by  the  fibers  of  the  hyoglossus  muscle 
(E.).  The  fibers  of  the  latter  are  separated  -within  the 
triangle,  exposing  the  artery   (F). 


1026    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


PECTORAUS  MAJOR,  DIVIDED  IN  COURSE  OF  FIBERS  y, 

DEEP  FASCIA  (COSTOCORACOlO  MEMBRANE)  y 
CEPHALIC    \/EINy 


where  it  enters  the  right  subclavian  vein;  immediately  behind  this, 
and  obtrusively  manifest,  lies  the  first  portion  of  the  artery  (Fig.  503), 
not  deeply  hidden  but  well  out  of  the  thoracic  cavity  and  easily 
accessible  to  further  attack.  The  subclavian  vein  with  the  stump  of 
the  internal  jugular  is  drawn  gently  forward ;  the  carrier,  armed  with 
a  double  floss  silk  ligature  and  grasped  in  the  jaws  of  a  needle  holder, 
encircles  the  artery  and  the  vessel  is  obliterated  with  a  stay  knot. 
The  sternothyroid  and  sternohj-oid  muscles  are  released ;  the  divided 
slernomastoid  is  apposed  with  two  chromic  gut  sutures;  the  super- 
ficial flap  is  turned 
up  into  place  and 
held  there  with  silk- 
worm gut  sutures. 

The  second  portion 
of  the  subclavian 
artery,  because  of 
its  location  behind 
the  scalenus  anticus 
muscle,  is  not  tied  in 
its  continuity. 

The  third  portion 
of  the  suhclavian 
artery  may  be  ex- 
posed on  either  side 
through  the  curved 
atypical  incision 
just  described  (in 
connection  with  liga- 
ture of  the  first  por- 
tion on  the  right 
side) ,  or  through  the 

one  about  to  be  described.  The  reader  is  again  asked  to  take  into  con- 
sideration the  feasibility  of  exposing  the  artery  in  this  situation  by  the 
emplo\Tnent  of  a  technic  suitable  to  the  surgical  problem  at  hand. 
The  practicability  of  this  suggestion  is  borne  out  by  the  frequency 
with  which  the  artery  is  exposed  during  resection  of  the  internal 
jugular  vein  for  the  relief  of  thrombosis  in  connection  with  infections 
of  the  mastoid  cells,  during  the  removal  of  tuberculous  glands  from 
the  neck,  or  the  enucleation  of  hnnph  nodes  from  the  subclavian  tri- 
angle in  the  radical  operation  for  relief  of  carcinoma  of  the  breast. 


Fig.    508.- 


[ACROMIC 
yhORACIC 
[BRANCH  . 

Exposure   of   the   First  Portion   of   the 
Axillary  Artery  (right). 


LIGATURE  OF  ARTERIES  IX  THEIR  CONTINUITY     1027 

The  following  description  is  that  of  the  cla.isic  method,  and  may  be 
regarded  as  indicative  of  the  factors  to  be  taken  into  account  in  ligat- 
ing  the  vessel.  The  patient  is  postured  with  the  head  extended  and 
the  chin  turned  to  the  opposite  side.  Intratracheal  narcosis  is  desir- 
able. The  integument  is  drawn  evenly  downward  and  incised  (four 
inches  in  length)  upon  the  clavicle  so  that  it  will,  when  allowed  to 
retract,  carry  the  incision  ujDward  to  half  an  inch  above  the  clavicle 
(Fig.  501E)  ;  the  superficial  fascia  and  the  platysma  are  divided, 
avoiding  the  external  jugailar  vein  (or  it  may  be  cut  between  two  liga- 
tures). The  suprascapular  and  transverse  cervical  veins  may  be 
treated  in  the  same  way.  The  omohyoid  is  sought  for  and  drawn 
upward  ;  the  suprascapular  artery  is  avoided. 

The  deej)  cervical  fascia  is  opened  and  the  outer  edge  of  the  scalenus 
anticus  located  and  followed  downward  to  the  tubercle  of  the  first  rib, 
immediately  behind  which  the  artery  is  felt.  The  artery  is  carefully 
isolated  from  the  vein,  which  lies  in  front  of  the  muscle;  the  ligature 
is  passed  from  before  backward.  Floss  silk  is  the  ligature  material  of 
choice  and  should  be  tied  with  a  stay  knot.  Fig.  504  gives  a  good 
notion  of  the  anatomical  condition  and  shows  the  artery  as  it  lies 
normally,  i.  e.,  well  above  the  clavicle,  and  the  relationship  the  brachial 
plexus  bears  to  it. 

Ligation  of  the  Carotid  Arteries. —  The  common  carotid  artery  is  no 
longer  tied  in  its  continuity.  Its  exclusion  from  the  circulation  does 
not  (because  of  the  abundant  collateral  connections)  control  the  flow 
of  blood  in  the  zone  of  its  distribution  long  enough  to  accomplish  the 
purpose.  At  one  time,  both  arteries  were  tied  for  the  relief  of  epi- 
lepsy; this  has  been  abandoned.  It  is  conceivable  that  it  may  be 
exposed  for  the  purpose  of  a  IMatas  arterial  repair  of  an  aneurism 
(p.  98)  of  the  vessel  itself,  or  may  be  temporarily  occluded  so  as  to 
give  the  surgeon  an  opportunity  to  perform  an  operation  in  the  region 
of  its  two  primar}'  branches.  However,  provision  for  the  permanent 
arrest  of  bleeding  would  have  to  be  made  and  the  common  carotid 
released  before  the  surgeon  would  be  justified  in  closing  the  wound. 
The  artery  is  often  encountered  in  operations  upon  the  deeper  tissues 
of  the  neck.  Its  exposure  is  easy.  In  the  past,  it  has  been  customary 
to  describe  the  ligature  of  the  artery  in  two  places,  ahove  and  'below 
the  omohyoid.  At  the  present  time,  this  distinction  is  regarded,  as  far 
as  exposure  is  concerned,  as  unnecessary. 

The  artery  is  exposed  &//  an  incision  along  the  anterior  border  of 
the  sternomastoid  muscle,  beginning  on  a  level  with  the  hvoid  bone 


1028     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


and  extending  three  inches  downward  (Fig.  501F).  The  skin,  super- 
ficial fascia,  platysma,  and  deep  fascia  are  divided,  exposing  the 
anterior  border  of  the  sternomastoid  muscle.  As  the  latter  is  pulled 
outward,  the  common  sheath  is  uncovered  (usually  the  descendens  noni 
nerve  lies  on  it)  crossed 
by  the  omohyoid  muscle 
(Fig.  505).  Then,  either 
above  or  below  the  lat- 
ter, the  internal  jugular 
vein  is  drawn  aside 
cautioush^ ;  the  sheath  of 
the  vessel  is  opened  and 
the  occluding  agent  is 
introduced  from  without 
inward ;  the  operator 
must  be  certain  that  the 
pneumogastric  nerve  is 
not  included.  The 
wound  is  closed  with  in- 
terrupted silkworm  gut 
sutures. 

The  inferior  thyroid 
artery  is  approached 
through  the  same  in- 
cision employed  for  t}'- 
ing  the  common  carotid 
(see  above) .  The  carotid 
sheath  and  its  contents, 
along  Avith  the  sterno- 
mastoid muscle,  are 
drawn  outward  and  the 
vessel  is  found  behind 
the  carotid  running 
inward. 

It  is  probable  that  the 
external    carotid    is   tied    in    its    continuity    more    often    than    any 
other    artery    in    the    body.      This    is    understandable    Avhen    it    is 
considered   that    its   occlusion   makes   extensive   surgical    procedures 
involving  the  face  and  mouth  possible.     The  vessel  is  best  tied  above 


Fig.  509. —  Exposure  of  Axillary  and  Brachial 

Arteries. 

Above,  axillary  artery:  A,  eoraeobraeliialis 
muscle;  B,  deep  axillary  fascia;  C,  median  nerve; 
D,  cutaneous  nerve ;  E,  internal  cutaneous  nerve ; 
F,  axillary  artery.  Below,  brachial  artery:  A, 
biceps  muscle;  C,  brachial  fascia;  D,  median 
nerve;  E,  brachial  artery;  F,  vein. 


LIGATURE  OF  ARTERIES  IN  THEIR  CONTINUITY    1029 

the  point  where  the  superior  thyroid  artery  is  given  off.  This  opera- 
tion too  has  been  surrounded  by  an  atmosphere  of  mystery.  As  a 
matter  of  fact,  the  vessel  is  constantly  exposed  during  operations  on 
the  neck,  and  its  ligature  in  its  continuity,  if  performed  through  an 
ample  incision,  is  not  at  all  fraught  vi^ith  difficulties. 

The  patient  is  postured  with  the  head  extended  and  the  chin  turned 
toward  the  opposite  side.  Intratracheal  narcosis  is  not  necessary,  but 
the  maintenance  of  narcosis  through  the  nose  with  the  narcotist 
remote  from  the  operative  field  is  desirable.  Because  of  the  disturb- 
ances of  the  parts  coincident  to  swallowing,  local  anesthesia  (except 
for  a  special  reason)  is  objectionable. 

The  incision  of  approach  divides  the  skin,  superficial  fascia,  and 
platysma  along  the  anterior  border  of  the  sternomastoid,  beginning 
opposite  the  angle  of  the  jaw  and  ending  on  a  level  with  the  inferior 
border  of  the  thyroid  cartilage  (Fig.  501G),  exposing  the  anterior 
edge  of  the  sternomastoid  muscle.  The  loose  connective  tissue  which 
surrounds  the  great  vessels  and  nerves  is  separated  by  blunt  dissection 
parallel  with  their  .course.  This  maneuver  uncovers  the  internal 
jugular  vein  and  the  common  facial  vein,  which  crosses  and  lies  imme- 
diately over  the  bifurcation  of  the  common  carotid  artery  (this  is  the 
key  to  the  operation).  The  common  facial  vein  is  cut  between  two 
ligatures  and  its  outer  stump,  together  with  the  internal  jugular,  is 
pulled  outward  (Fig.  506).  Thus  is  exposed  in  the  upper  angle  of 
the  wound  the  posterior  belly  of  the  digastric  muscle  and  the  hypo- 
glossal nerve,  which  crosses  over  the  external  carotid  and  its  branch, 
the  lingual  artery,  and  in  the  center  of  the  wound  the  bifurcation 
of  the  common  carotid  is  plainly  visible  —  a  pinkish  white,  double 
cylinder  shimmering  through  its  surrounding  bundles  of  trans- 
parent connective  tissue  (Fig.  506).  The  latter  is  separated;  the 
external  carotid  artery  is  recognized  by  its  branches  (chiefly  the  first, 
superior  thyroid)  ;  the  ligature  is  passed  around  the  vessel  from  with- 
out inward,  above  the  superior  th^Toid,  and  tied  with  a  stay  knot. 

The  internal  carotid  artery  may  be  tied  by  exposing  it  in  precisely 
the  same  manner  described  (immediately  above)  in  connection  with 
the  external  carotid  artery. 

The  superior  thyroid  artery  may  be  tied  through  the  same  incision 
as  is  used  for  ligature  of  the  external  and  internal  carotids. 

Ligation  of  the  Lingual  Artery. —  The  lingual  artery  may  be  ligated 
through  the  incision  employed  for  exposure  of  the  external  carotids, 
or  as  follows:    A  creseentie  incision  is  made  a  finger's  breadth  below 


1030    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

the  margin  of  the  jaw  (Fig.  501H).  After  division  of  the  skin  and 
platysma  the  superficial  cervical  fascia  comes  into  view ;  this  is  divided 
along  the  lower  border  of  the  submaxillary  gland,  and  the  latter, 
together  with  the  flap,  is  lifted  from  its  bed,  thus  exposing  the  arched 
tendons  of  the  digastric  muscle  and  the  hypoglossal  nerve  with  its 
attendant  vein  lying  beneath  the  deep  layer  of  fascia.  The  free  edge 
of  the  mylohyoid,  the  tendon  of  the  digastric  muscle  and  the  hj-po- 
glossal  nerve  form  a  triangle,  in  the  bottom  of  which  lie  the  fibers  of 
the  hypoglossal  muscle  (Fig.  507).  To  ligate  the  arierij,  the  fascia 
over  the  triangle  is  opened  and  the  fibers  of  the  hypoglossal  muscle  are 
separated. 

Ligation  of  the  Axillary  Artery. —  Ligature  of  the  first  portion  of  the 
axillary  artery  is  performed  as  follows:     Turn  the  patient's  head  to 


Fig.  510. —  !Mayo  Scissors,  Straight  and  Curved. 


the  opposite  side  and  slightly  abduct  the  arm.  ]\Iake  an  incision  four 
inches  in  length,  one  half  inch  below  the  clavicle,  beginning  an  inch 
from  its  sternal  end,  dividing  the  skin,  platysma,  and  fascia  ;  separate 
the  fibers  of  the  pectoral  is  major  from  the  deltoid  (avoiding  the 
cephalic  vein^.  or  divide  those  of  the  former  muscle  the  full  length  of 
the  wound  (Fig.  5011)  ;  tear  asunder  the  costocoracoid  fascia  at  the 
upper  border  of  the  pectoralis  minor  muscle,  bring  the  arm  to  the  side 
to  relax  this  muscle,  which  is  then  drawn  outward ;  displace  the 
areolar  tissue  with  the  handle  of  the  knife,  thus  exposing  the  vein, 
which  should  be  carefully  drawn  downward  and  inward  with  a  blunt 


LIGATUEE  OF  ARTERIES  IX  THEIR  COXTINXITY     1031 

hook ;  this  maueuver  brings  into  view  the  artery  lying  in  close  contact 
with  the  inner  cord  of  the  brachial  plexus,  located  to  the  outer  side 
and  above  the  vessel  (Fig.  50S).  The  carrier  is  best  introduced 
between  the  artery  and  the  nerve  and,  with  the  vein  held  aside,  the 
ligature  is  delivered  at  the  inner  side  of  the  artery;  tie  with  a  square 
knot  and  close  the  wound  with  silkworm  gut  (without  drainage). 

To  tie  the  brachial  artery  at  its  middle  third,  make  an  incision  three 
inches  in  length  along  the  inner  edge  of  the  biceps  muscle  (in  the 
sulcus  bicipitalis  iuternus),  dividing  the  skin  and  the  bicipital  fascia, 
clearly  exposing  the  fibers  of  the  muscle.  Draw  down  the  lower  lip  of 
the  wound,  exposing  the  median  nerve ;  this  is  freed  with  scissors  and 
is  also  dra^v^l  downward,  uncovering  the  arterj'  with  its  attendant  vein 
(Fig.  509)  ;  the  latter  is  also  separated  from  the  vessel  with  the  scis- 
sors and  the  artery  is  encircled  with  the  ligature,  which  is  tied  in  a 
square  knot.  The  wound  is  closed  with  interrupted  silkworm  gut 
sutures  without  drainage. 


BIBLIOGRAPHY 

1.  Ballaxce  and  Edmuxds.     Med.  and  Surg.  Trans..  London.  1886. 

2.  Jacobsox  and  Steward.     Op.  of  Surg,  ii,  Phila..  1902. 

3.  Brtaxt.     Op.  Surg,  i,  Appleron.  Xew  York  and  London,  1905. 

4.  Barx'^'ell.     Intern.  Encycl.  of  Surg.,  London,  iii. 

5.  Kast.     Zeitschr.  f.  Chir.  Bd.  xii. 

6.  MoxTEiRO.     Quoted  by  Jacobson  Xo.  2. 

7.  Keex".     Amer.  Jr.  of  Med.  Sci.,  September,  1900. 

8.  TiLLAUX  and  Riche.     Revue  de  chir..  1901. 

9.  Cramptox.     Quoted  by  Jacobson  Xo.  2. 

10.  KocHER.     Cbir.  Op.  Lehre,  Jena,  1907. 

11.  Dexxis.     Anns.  Surg,  v,  Xo.  i. 

12.  ZrcKERKAXDL.     Cbir.  Op.  lehre.  Munich.  1905. 

13.  :Mott.     X.  Y.  :Med.  and  Surg.  Register.  1818. 

14.  Cooper.     Amer.  Jr.  of  Med.  Sci.,  1859.  xxxviii. 

15.  Smyth.     Svd.  Soc.  Bien.  Retr..  1865-1866. 

16.  Lewtas.     Brit.  Med.  Jr.,  1889.  ii. 

17.  CoPPixGER.     Trans.  Royal  Acad.  Med.,  Ireland,  xi.  1893. 

18.  Stmoxds.     Personal  communication  to  Jacobson  Xo.  2. 

19.  BuRRELL.     Boston  Med.  and  Surg.  Jr.,  August  8,  1895. 

20.  Bardexhefer.     Deutscb.  med.  TTocb..  1885. 

21.  MoYXiHAX.     Anns.  Surg..  Phila..  1898.  xviii. 

22.  Cl-ktis.     Anns.  Sure.,  Phila..  1901.  xxxiv. 

23.  CouGHLix.     Sure.  Gvn.  Obst.,  1918,  Xo.  1. 

24.  DOTEX.     Op.  Surff.  ii,  1918. 


CHAPTER  VI 
DISEASES    OF    PEEIPHERAL    XEEVES 

Neuralgia. —  Neuralgia  ma}'  be  defined  as  a  purely  clinical  disturb- 
ance of  the  nervous  system,  ^Yllich  may  occur  as  an  independent 
affection  {true  neuralgia)  or  as  a  manifestation  of  general  or  local 
diseases  of  the  nerves  {symptomatic  or  secondary  neuralgia).  In  the 
former  instance,  demonstrable  pathological  changes  are  absent.  The 
most  important  characteristic  of  neuralgia  is  severe,  paroxysmal  pain 
in  the  course  of  a  hranch  or  the  trunk  of  a  nerve  or  in  a  nerve  plexus. 
The  pain  is  radiating  in  character^  disappears  completely  or  incom- 
pletely in  from  a  few  minutes  to  a  few  hours,  and  may  be  caused  to 
recur  or  become  exacerbated  by  trivial  causes,  such  as  pressure  or  slight 
muscular  movements. 

The  onset  of  the  affliction  (which  commonly  occurs  in  middle  life)  is 
usuall}'  sudden  and  severe,  though  it  may  be  moderate  at  first  and 
gradually  increase.  Subsequent  attacks  are  often  heralded  b}'  prodro- 
mata  such  as  tingling  or  ''drawing  pains,"  but  these  maj'  be  absent. 
The  intervals  between  attacks  vary  from  hours  to  days.  During  the 
acme  of  an  attack  the  pain  not  infrequently  radiates  to  contiguous 
zones. 

The  course  of  the  affection  may  terminate  in  a  few  days  or  may 
extend  over  montLs  and  years.  Recession  is  as  likely  as  is  extension  to 
other  nerves  of  the  same  trunk  or  plexus.  The  peculiarly  distressing 
character  of  the  affliction,  especially  in  cases  of  trifacial  neuralgia,  may 
last  until  death  (not  infrequently  by  self  destruction)  affords  relief. 

The  disturbances  consequent  to  interference  with  nerve  function  are 
exceedingly  variable.  These  relate  primarily  to  modification  of  sensa- 
tion, which  is  expressed  by  hyperesthesia,  more  often  than  by 
anesthesia.  Glandular  secretion  is  increased  (lachrjTnation,  saliva- 
tion, sweating)  and  the  sliin  is  alternately  red  and  pale.  During  an 
attack  the  motor  reflexes  are  increased,  causing  the  muscles  to  twitch. 
This  is  seen  in  the  facial  muscles  in  trigeminal  neuralgia.  Trophic 
disturbances  are  especially  marked  in  the  skin,  which  is  atrophic;  the 

1032 


DISEASES  OF  PERIPHERAL  NERVES  1033 

hairs  fall,  and  eczema  and  herpes  zoster  make  their  appearance  (thorax 
and  face). 

The  general  condition  of  the  patient  gradually  suffers  from  loss  of 
sleep,  and,  in  trigeminal  neuralgia,  from  inability  to  masticate  without 
great  pain,  the  simple  introduction  of  food  into  the  mouth  often 
precipitating  an  agonizing  attack.  Ultimately,  severe  psychic  changes 
(irritability,  melancholia)  develop. 

The  causes  of  neuralgia  are  general  and  local.  The  predisposing 
factors  consist  of  a  neuropathic  tendency ;  physical  and  mental  ex- 
haustion combined  with  emotional  disturbance  and  sexual  excesses; 
lessened  general  resistance  and  chronic  obstipation.  The  direct  gen- 
eral factors  are  infectious  diseases  (maleria,  typhus,  variola,  influ- 
enza), and  toxic  substances  such  as  lead,  copper,  mercury,  alcohol,  and 
nicotin.  Diabetes  mellitus  is  often  attended  with  neuralgia,  which  is 
attributed  to  disturbances  of  metabolism.  The  local  causes  are  cold 
(wet,  and  draughts),  contusions  and  lacerations  of  nerves,  the  pres- 
sure of  foreign  bodies,  and  scar  tissue,  which  encases  the  nerve  and 
often  causes  it  to  adhere  to  the  bone;  fractures,  aneurisms,  varices, 
gummata,  tumors  (including  amputation  neuroma),  and,  finalh',  in- 
fiammatorg  processes  in  the  areas  of  nerve  endings  or  in  the  course  of 
nerve  trunks,  such  as  purulent  periostitis  in  the  lower  jaw,  and  in  the 
accessory  sinuses  of  the  nose,  carious  teeth,  ulcers  of  mucous  mem- 
branes, tuberculosis  of  the  vertebras,  the  sternum  and  the  ribs. 

Neuralgic  pain  also  occurs  in  connectiori  ivith  tumors  and  other 
lesions  of  the  central  nervous  system,  such  as  tumors  of  the  cerebello- 
pontile  angle  and  the  spinal  cord,  tabes  dorsalis,  luetic  meningitis,  and 
multiple  sclerosis  (Oppenheim,^  Krause,-  etc.). 

Of  the  various  forms  of  neuralgia,  that  of  the  trigoninus  is  the 
most  common ;  then  follow  in  order  of  f requenc}^  neuralgia  of  the 
sciatic,  the  intercostal  and  the  occipital  nerves;  of  the  nerves  of  the 
lumbar,  pudendohemorrhoidalis  and  coccygeal  plexuses,  and  of  the 
extremities. 

The  diagnosis  of  neuralgia  is  based  on  the  observation  that  the 
pain  corresponds  to  the  anatomical  distribution  of  a  nerve  and  ex- 
tends beyond  it  only  during  the  acme  of  an  attack,  and  that  pressure 
on  certajin  points,  the  so-called  "pain  points,"  elicits  pain  or  may 
provoke  an  attack.  These  points  correspond  to  where  a  nerve  trunk 
or  one  of  its  branches  emerges  from  a  bone  canal,  or  where  it  can  be 
pressed  against  the  bone  or  against  a  resisting  fascial  band ;  for  in- 
stance, in  sciatic  neuralgia  at  the  edge  of  the  gluteus  maximus,  in  the 


1034    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

middle  of  the  popliteal  space,  and  below  the  head  of  the  fibula;  in 
supraorbital  neuralgia  at  the  incisura  supraorbitalis  and  the  infra- 
orbital at  its  foramen  of  exit. 

A  careful  search  should  always  be  made  for  the  local  and  constitu- 
tional causes  of  neuralgia,  as  the  treatment  is  primarily  directed 
toward  its  correction.  This  is  illustrated  in  malarial  neuralgia,  which 
often  vanishes  after  the  administration  of  quinin,  and  in  sciatic  neu- 
ralgia due  to  the  pressure  of  a  pelvic  tumor,  which  disappears  after 
removal  of  the  growth.  Bilateral  neuralgia  suggests  the  presence  of  a 
central  lesion,  such  as  a  tumor,  at  the  base  of  the  cranial  cavity  in 
trigeminal  neuralgia,  and  the  presence  of  a  spinal  tumor  or  tubercu- 
lous spondylitis  is  suspected  in  cases  of  intercostal  neuralgia ;  though 
the.se  diseases  may  cause  unilateral  neuralgia  and,  of  course,  are  not 
readily  recognized  unless  attended  with  other  symptoms.  The  false 
neuralgia  of  hysteria  and  inflammatory  neuritis  may  be  differentiated 
by  careful  examination. 

The  treatmeyit  of  neuralgia  is  most  likely  to  be  effectual  when  the 
cause  is  removable,  and  is  more  often  successful  when  this  is  local 
than  when  constitutional  factors  enter  into  the  etiology.  "When 
accessible  scar  tissue,  tumors,  fragments  of  bone,  foreign  bodies,  etc., 
are  removed,  and  when  the  attendant  inflammation  has  subsided  neu- 
ralgia is  very  likely  to  disappear.  The  general  treatment  should  be 
directed  toward  correction  of  the  underlying  disturbance,  the  proper 
adjustment  of  the  mode  of  life,  improvement  of  the  general  health,  and 
attention  to  the  excretory  functions. 

When  general  or  local  treatment  is  unsuccessful,  or  when  the  causa- 
tive factor  is  not  discernihle,  the  horde  of  remedies  over  which  internal 
medicine  rules  may  be  drawn  from.  Those  most  often  used  are 
quiiiin,  arsenic,  the  hromids,  aconitin,  aspirin,  and  pyramidon,  sup- 
plemented by  the  local  application  of  heat  and  electricity ;  injections 
of  cocain,  eucain,  Schleich's  solution,  etc.,  into  the  vicinity  of  the 
nerve  for  the  purpose  of  temporary  insensibility;  or  one  per  cent 
osmic  acid  may  be  injected  with  the  view  of  causing  degeneration  of 
nerve  fibres.  In  severe  cases,  morphin  must  be  used ;  however,  oper- 
ative efforts  at  relief  should  be  made  before  the  required  dosage  en- 
tails the  danger  of  chronic  morphinism. 

When  a  rational  trial  of  these  various  measures  fails  to  relieve,  or 
when  the  general  condition  of  the  patient  does  not  justify  persistence 
in  their  employment,  surgical  attach  upon  the  nerve  may  properly 
be  made.     However,  operative  measures  upon  peripheral  nerves  do 


DISEASES  OF  PERIPHERAL  NERVES  1035 

not  afford  relief  when  neuralgia  is  due  to  a  central  lesion,  and  pain 
returns  even  though  the  nerve  Ls  removed. 

When  the  destruction  of  conductivity  of  sensory  nerves  or  of  mixed 
nerves,  such  as  the  third  division  of  the  trigeminus  (which  is  par- 
tially motor),  is  not  followed  by  serious  loss  of  function,  section 
{neurotomy),  resection  {neurectomij),  and  avulsion  (extraction)., 
may  be  employed.    In  other  mixed  nerves  stretching  may  be  used. 

Neurotomy,  because  of  the  rapid  repair  of  the  nerve,  usually  is  soon 
followed  by  return  of  pain.  Neurectomy  is  more  successful,  but  here 
too  there  is  the  danger  of  union  of  the  separated  ends  and  return  of 
pain  unless  a  large  section  is  removed.  Nerve  extraction  (introduced 
by  Thiersch,^  1889)  is  mos-t  likely  to  be  followed  by  relief,  especially 
in  cases  of  trigeminal  neuralgia.  The  aim  of  the  procedure  is  to 
remove  a  portion  of  the  nerve  trunk  together  with  all  of  its  peripheral 
branches.  The  nerve  is  exposed  as  near  its  central  end  as  possible, 
and  is  grasped  by  means  of  a  suitable  forceps  and  slowly  twisted  or 
"rolled  up"  on  the  instrument  until  all  of  its  attachments  give  way. 
The  removal  must  be  slowly  and  carefully  executed :  10  to  20  cm.  of 
nerve  may  be  extracted  in  this  way. 

The  pain  not  infrequently  returns  after  neural  extraction,  es- 
pecially in  cases  of  neuralgia  of  the  trigemmus.  Recurrences  are 
due  to  regeneration  of  the  nerve  from  central  fibers  not  removed  hy 
extraction.  For  the  relief  of  this  class  of  cases  Krause*  (1892)  de- 
vised the  technic  of  removal  of  the  ganglion  of  Gasser,  though  Hors- 
ley^  had  sectioned  the  nerve  roots  before  this.  Lexer'''  seems  to  have 
shown  that  there  is  less  likelihood  of  recurrence  of  pain  when  the 
bony  canals  at  the  base  of  the  skull  are  filled  with  wax  or  paraffin 
after  the  branches  of  the  nerve  are  removed. 

Persistent  neuralgia  of  mixed  nerves  justifies  invasion  of  the  spinal 
cord  (by  laminectomy)  and  resection  of  the  nerves  which  supply  the 
area  of  pain.  When  pain  is  attended  with  muscular  spasm,  it  is  not 
necessary  to  open  the  dura,  since  extradural  division  of  both  nerves 
is  sufficient  to  afford  relief  (Schede"). 

On  the  theory  that  neuralgia  is  due  to  venous  hyperemia  of  the 
nerve  where  it  passes  through  its  foramen  of  exit  (trigeminus,  sciatic), 
Bardenheuer®  recommends  operative  enlargement  of  the  foramina, 
followed  by  implantation  of  a  muscle  flap  between  the  nerve  and  the 
bone.    The  measure  is  of  doubtful  utilit3^ 

Nerve  stretching  was  first  carried  out  by  Billroth'*  in  1869,  and 
elaborated  by  Nu.ssbaum.^" 


1036     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

In  1872,  Gartner^^  emplo^'ed  the  measure  for  the  relief  of  neuralgia 
following  subcutaneous  contusion  of  the  brachial  plexus.  Subse- 
quently the  method  was  used  by  many  others  for  the  relief  of  neuralgic 
pain.  The  sciatic  was  stretched  for  the  relief  of  pain,  in  connection 
with  tahes,  by  Langenbuch  ;^-  the  facial  nerve  for  spasm  of  the  face 
and  trigeminal  neuralgia;  and  the  accessorius  for  relief  of  the  spasm 
of  tetanus  by  Voght^^  and  others.  Too  much  was  expected  of  the 
method  and  it  soon  fell  in  disuse.  However,  according  to  Schede/ 
nerve  stretching  is  valuable  not  alone  in  cases  of  neuralgia  of  mixed 
nerves  attended  with  muscular  spasm,  but  also  when  the  pain  is 
severe  in  neuritis.  Complete  relief  does  not  always  obtain,  but  the 
symptoms  are  markedly  improved.  On  the  other  hand,  extraction  of 
sensory  nerves  has  quite  displaced  stretching,  and  in  spinal  lesions  it 
is  also  no  longer  used  (Schede'). 

For  the  purpose,  the  nerve  is  exposed,  separated  from  its  surround- 
ings, grasped  by  the  fingers  or  by  forceps,  and  forcibly  stretched  in  its 
long  axis. 

The  beneficial  effect  of  nerve  stretching  is  believed  to  be  due  to  the 
lessening  of  conductivity  which  follows  the  trauma;  to  the  changes 
sequential  to  degeneration  and  regeneration  of  nerve  fibers ;  and  to 
separation  of  adhesions.  The  best  results  have  followed  Moodless 
stretching  of  the  sciatic  nerves  for  relief  of  neuralgia.  The  patient 
is  narcotized  and  the  straightened  extremity  is  flexed  at  the  hip  joint 
until  the  leg  comes  in  contact  with  the  face.  This  posture  is  main- 
tained for  five  minutes. 

Neuritis. — Neuritis,  or  inflammation  of  a  nerve,  is  an  acute  or 
chronic  serous  or  seropurulent  inflammation  of  the  perineurium  and 
interstitial  tissues,  which  is  followed  by  degeneration  of  nerve  fibers 
and,  ultimately,  by  proliferation  of  nerve  connective  tissue.  The  af- 
fected nerve  is  red  and  swollen  as  the  result  of  inflammatory  infiltra- 
tion and  hyperemia  and  is  often  fusiform  in  outline.  Later,  when 
proliferation  of  connective  tissue  supervenes,  the  ner^^e  is  thickened, 
irregularly  nodular,  and  more  or  less  intimately  adherent  to  its  sur- 
roundings. 

The  causes  of  neuritis  are  mechanical  and  the  effect  of  toxic  sw6- 
stances  upon  nerves.  To  the  former  belong  contusions  and  lacerations ; 
repeated  pressure  and  the  shock  from  workingmen's  tools  (occupa- 
tional neuritis)  or  from  the  use  of  crutches  (musculospiral)  ;  pressure 
of  bone  splinters,  calluses  after  fracture,  dislocated  articular  surfaces, 
foreign  bodies  (bullets,  knife  blades,  etc.),  tumors,  cervical  ribs,  etc. 


DISEASES  OF  PERIPHERAL  NERVES  1037 

In  open  injuries  of  nerves  the  destructive  effect  of  the  trauma  is  often 
supplemented,  by  bacteriotoxic  causes.  The  latter  must  also  be  taken 
into  account  in  cases  of  pyogenic  or  tuberculous  infections  of  bones 
or  joints  which,  by  extension,  not  infrequently  invade  contiguous 
nerves.  In  many  instances  the  toxins  of  acute  infectious  diseases 
(general  pyogenic  infections,  especially  those  of  puerperal  origin, 
typhoid,  diphtheria,  syphilis,  tuberculosis,  etc.)  and  chronic  poisoning 
(lead,  arsenic,  alcohol,  nicotin,  etc.),  are  responsible  for  neuritis.  To 
these  may  be  added  the  effects  of  cold,  rheumatism,  gout,  diabetes  mel- 
litus,  leukemia,  and  arteriosclerosis.  That  is  to  say,  all  of  the  consti- 
tutional factors  which  stand  in  a  causative  relationship  to  patho- 
logical changes  in  the  tissues  are  generally  of  etiological  significance 
in  neuritis. 

The  inflammatory  processes  in  nerves  sequential  to  local  causes 
gradually  extend  toward  the  peripherj^  (descending  degeneration) 
and  toward  the  spinal  cord  (ascending  degeneration)  ;  those  that  are 
due  to  general  causes  usually  simultaneously  involve  several  nerves 
{multiple,  or  polineuritis) .  This  is  illustrated  in  cases  of  lead  and 
arsenic  poisoning  which  usually  are  attended  with  paralj^sis  of  the 
extensors  of  the  hands  and  feet  —  rarely  the  flexors  —  while  in  dip- 
theria  any  group  of  muscles  may  be  affected. 

Acute  neuritis  is  ushered  in  by  a  chill,  fever,  and  pain  which  is 
boring  and  tearing  in  character,  extends  over  the  entire  course  of  the 
nerve  and  is  increased  in  intensity  by  pressure  or  by  muscular  exer- 
tion. To  these  are  added  evidence  of  nerve  irritation  in  the  zone  of 
motor  and  sensory  distribution,  consisting  of  hyperesthesia  and  muscu- 
lar contraction  followed  by  disturbances  in  conductivity,  i.  e.,  disap- 
pearance of  tendon  reflexes,  anesthesia,  trophic  disturbances,  motor 
paresis,  and,  later,  muscular  atrophy  and  the  reaction  of  degeneration. 

Chronic  neuritis  (when  not  sequential  to  the  acute  form)  is  insid- 
ious in  its  onset.  The  pain  is  not  as  severe,  and  is  intermittent  or  re- 
mittent in  character.  As  a  rule,  the  process  is  attended  with  the  for- 
mation of  insular  areas  of  thickening  in  the  course  of  the  nerve 
{neuritis  nodosa). 

Regeneration  of  nerves,  in  the  acute  form  of  neuritis,  may  occur 
in  a  few  weeks  and  all  the  sj^mptoms  maj'  disappear  within  that  period 
of  time.  The  chronic  form  is  likely  to  be  obstinate  and  is  often  fol- 
lowed by  permanent  functional  disturbances. 

Differentiation  of  neuritis  from  neuralgia  cannot  always  be  estab- 
lished with  certainty.     Consideration  of  character  of  pain  is  of  diag- 


1038    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

nostic  value.  In  neuritis  the  pain  is  constant,  though  it  is  less  severe 
at  intervals ;  in  neuralgia  it  is  present  only  during  an  attack  and  is 
elicited  by  pressure  only  at  certain  points  (pain  points)  ;  in  neuritis 
the  nerve  is  tender  in  its  entire  course  and  may  be  palpably  hardened 
and  thickened.  Neuralgia  is  not  attended  with  the  motor  and  sensory 
disturbance  common  to  neuritis.  Multiple  fibromata  are  usually  at- 
tended with  fibrous  and  pigmented  deposits  in  the  skin  and  do  not 
exhibit  the  disturbance  of  nerve  conduction  so  essentially  a  part  of 
neuritis  nodosa. 

The  treatynent  of  neuritis,  due  to  local  mechanical  and  inflammatory 
causes  (besides  operative  removal),  consists  of  immobilization  of  the 
part  in  which  the  affected  nerve  is  located.  Morphin,  or  other  ano- 
dynes, sodium  salicylate,  salol  and  aspirin  may  be  administered.  In 
chronic  cases,  regeneration  is  assisted  by  massage,  the  use  of  the 
electrogalvanic  current,  and  baths.  Contractures  of  muscles  and 
paralyses  receive  special  treatment. 

When  a  nerve  is  exposed  for  the  purpose  of  removing  a  foreign 
body  or  scar  tissue,  it  should  be  dissected  out  to  a  considerable  extent 
beyond  the  seat  of  the  causative  factor  with  the  view  of  loosening 
adhesions  of  the  perineurium  and  for  the  purpose  of  nerve  stretching. 
In  chronic  cases  the  latter  step  not  alone  separates  adhesions  but  also 
stimulates  regeneration  of  nerve  fibers  (see  nerve  stretching). 

BIBLIOGRAPHY 

1.  Oppenheim.     Lehrb.  d.  Nervenkrank,  Berlin. 

2.  Krause.     Neurolgia  d.  Trigeminus,  Leipzig,  1896. 

3.  Thiersch.     Chir.^kong.  Verb.,  1889,  i. 

4.  Krause.     Leipzig,  1896. 

5.  HoRSLEY.     Same  as  No.  6. 

6.  Lexer.     Arch.  f.  klin.  Chir.,  Bd.  65,  1902. 

7.  ScHEDE.     Penzoldt  and  Stintzing,  Handb.  d.  Spec.  Therap.  (2d  ed.)  v, 

with  lit. 

8.  Bardenheuer.     Chir.  kong.  Verb.,  1906,  i. 

9.  Billroth.     See.  ^o.  7. 

10.  NussBAUM.     See  No.  7. 

11.  Gartner.     See  No.  7. 

12.  Langenbuch.     See  No.  7. 

13.  Voght  and  others.     See.  No.  7. 


CHAPTER  VI 
DISEASES  OF  JOINTS 

Luxations  and  Subluxations. — Luxations  and  subluxations  are  con- 
genital or  acquired. 

Of  congenital  dislocations,  those  of  the  hip  are  the  most  frequent. 
Girls  are  more  commonly  affected  than  boys.  The  lesion  is  more  often 
unilateral  than  bilateral  and  is  usually  associated  with  shallowness  of 
the  acetabulum.  Congenital  dislocations  of  the  shoulder,  knee,  elbow 
(usually  the  head  of  the  radius),  the  external  malleolus,  the  fingers 
and  patella  occur,  but  are  comparatively  rare. 

The  cause  of  congenital  and  inherited  dislocations  is  not  clear.  A 
number  of  theories  have  been  advanced  regarding  the  etiology  of  con- 
genital dislocation  of  the  hip  joint.  Of  these  the  one  based  on  the 
notion  that  the  lesion  is  due  to  malposition  of  the  fetus  in  utero  or  to 
some  irregularity  in  the  shape  of  the  uterus  is  the  most  probable.  A 
deficiency  of  amniotic  fluid  early  in  pregnancy  permits  the  uterus  to 
come  in  close  contact  with  the  fetu.s,  the  thigh  is  hyperflexed  and 
adducted  and  the  head  of  the  femur  grows  beyond  the  region  of  the 
acetabulum  (Hoffa^).  Amniotic  bands  probably  also  play  a  part  in 
the  causation  of  this  class  of  lesions. 

The  symptoms  of  congenital  dislocations  are  more  or  less  manifest 
in  the  contour  of  the  joint,  but  may  be  so  moderate  in  degree  as  to 
escape  recognition  for  a  long  time,  especially  in  dislocation  of  the  hip 
joints,  which  may  not  be  recognized  until  the  child  begins  to  walk. 

The  diagnosis  is  based  on  the  same  signs  and  symptoms  indicative 
of  traumatic  dislocations,  except  that  motility  is  not  interfered  with. 
In  fat  children  in  whom  subluxations  are  not  easily  recognized,  the 
X-ray  i.s  of  great  assistance. 

Reduction  of  congenital  dislocations  is  not  difficult  unless  too  long 
delayed,  when  the  soft  parts  become  shortened,  or  when  the  joint  has 
undergone  pathological  changes.  Retention  in  the  corrected  position 
is,  however,  a  more  difficult  problem  and  is  only  accomplished  after 
prolonged  use  of  proper  apparatus.    Attempts  at  reduction  should  be 

1039 


1040     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

preceded  b}'  stretching  of  the  muscles.  The  technic  of  reduction  is 
similar  to  that  employed  in  traumatic  cases.  When  reduction  as  stated 
is  unsuccessful,  the  open  operation  must  be  resorted  to ;  it  is  often  fol- 
lowed by  more  or  less  ankylosis. 

Pathological,  or  spontaneous,  dislocations  are  thus  termed  in  contra- 
distinction to  the  traumatic.    The}-  appear  in  three  forms. 

First. —  Distention  or  destruction  luxations,  which  are  due  to  dis- 
tention of  the  capsule  by  inflammatory  transudate  or  to  destruction  of 
the  articular  surfaces  and  the  capsule. 

Second. —  Those  due  to  stretching  of  the  capsule  following  patho- 
logical shortening  of  contiguous  bones,  such  as  occurs  at  the  wrist 
when  the  ulna  is  dislocated  after  the  radial  epiphysis  is  resected,  or 
when  the  radius  is  shortened  as  the  result  of  necrosis,  and  when  the 
head  of  the  fibula  is  displaced  outward  and  upward  after  necrosis  of 
the  tibia. 

Third. —  Paralytic  luxation,  when  all  the  muscles  of  a  limb  are 
paralyzed,  in  which  the  capsule  stretches  and  allows  the  articular 
surfaces  to  become  widely  separated  {paralytic  flail  joint).  Disloca- 
tions of  this  sort  are  easily  reduced,  but  immediately  recur.  The 
faulty  position  of  the  bones  is  clearly  defined  in  the  trophic  limb. 
When  only  a  group  of  muscles  is  paralyzed,  the  dislocation  is  caused 
by  the  contracture  of  the  unaffected  antagmiistic  muscles,  which  force 
the  bone  against  the  joint  capsule,  gradually  stretching  it  until  ulti- 
mately more  or  less  complete  dislocation  is  produced,  or  an  incomplete 
dislocation  is  suddenly  made  complete  by  an  abrupt  exertion  or  by 
comparatively  slight  trauma.  This  happens  at  the  hip  joint  when 
the  adductors  and  rotators  are  paralyzed,  the  head  of  the  bone  being 
gradually  forced  into  a  dorsal  dislocation. 

The  symptoms  and  diagnosis  of  pathological  dislocations  depend 
upon  the  underlying  cause.  The  diagnosis  is  based  on  the  abnormal 
position  of  the  articular  ends  of  the  bone,  preceded  by  the  symptoms 
of  the  pathological  causative  factor. 

The  treatment  consists  of  a  combination  of  reduction  of  the  malpo- 
sition and  the  removal  of  its  cause.  Reduction  should  be  attained 
gradually  by  means  of  extension  apparatus  rather  than  by  forcible 
manipulations.  Open  reduction,  resection,  etc.,  may  be  necessary. 
The  use  of  orthopedic  apparatus  and  tendoplasty  are  helpful  measures 
in  cases  of  paralytic  dislocation. 

Contractures  and  Ankylosis. —  The  term  contracture  is  used  to-day 
to  indicate  the  condition  in  which  joints  are  fixed  in  more  or  less 


DISEASES  OF  JOINTS  1041 

faulty  positions,  as  the  result  of  contraction  and  shortening  of  the 
soft  tissues  surrounding  them,  or  by  the  permanent  contraction  of  a 
group  of  muscles. 

Contractures  are  classified,  in  accord  with  the  position  assumed  by 
the  affected  part,  as  contractures  in  flexion,  extension,  ahductio^i, 
adductio)t,  rotation,  pronation,  and  supination.  Contractures  of  high 
degree  (usually  those  in  flexion)  cause  deformity  at  an  acute  angle, 
and  those  of  lesser  degree  at  an  obtuse  angle. 

The  articular  surfaces  may  bear  an  anatomically  normal  relationship 
to  each  other  and  may  be  held  in  position  by  fibrous  or  bony  ankjdosis, 
or  the}^  may  be  in  a  condition  of  luxation  or  subluxation. 

Congenital  contractures  are  in  part  due  to  arrested  development, 
and  are  then  usually  associated  with  bony  defects,  and  in  part  to 
infra-uterine  pressure,  the  result  of  the  absence  of  amniotic  fluid  or  of 
strangulation  by  amniotic  bands. 

Deformities  of  this  sort  appear  at  times  in  the  form  of  flexion 
contractures  at  the  hip,  knee,  wrist  joints,  and  in  the  little  finger; 
usually,  however,  they  involve  the  foot  in  the  form  of  the  different 
varieties  of  club  foot.  Spastic  contractures,  when  due  to  congenital 
defects  or  to  cerebral  injury  produced  during  birth,  are  also  included 
in  this  group. 

All  congenital  contractures  ultimately  lead  to  malposition  of  the 
affected  part  as  the  result  of  progressive  shrinkage  of  muscles, 
fascia,  and  ligaments  which  leads  to  interference  with  function. 

Acquired  contractures  are  dermatogenous,  desmogenous,  myogen- 
ous, neurogenous,  and  arfhrogenous  in  origin  (Hoffa^). 

Dermatogenous  contractures  are  produced  by  scleroderma  or  by 
dermal  scars,  and  may  be  corrected  by  excision  and  repair  by  suture  or 
by  transplantation  of  healthy  tissue. 

Desmogenous  contractures  are  caused  by  deeply  located  scars,  fol- 
lowing burns  or  necrosis  of  fascia  and  tendons.  In  the  hand  they 
result  from  contracture  of  the  palmar  aponeurosis,  in  which,  usually, 
the  fourth  and  fifth  fingers  and,  at  times,  the  thumb  are  strongly 
fiexed  (Dupuytren's  contracture). 

In  this  class  of  cases  excision  of  the  scar  tissue  is  the  most  effective 
plan  of  treatment.  It  is,  however,  necessary  also  to  excise  the  super- 
imposed skin,  which  is  always  firmly  attached  to  the  fascia.  The  re- 
sultant surfaces  must  be  covered  by  pediculated  or  free  dermal  flaps 
(Lexer-).  The  most  difficult  cases  are  those  in  which  cicatricial  con- 
tracture follows  purulent  tendovaginitis  (p.  321).  Forcible  stretching 


1042     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

and  immobilization  in  the  corrected  position,  excision  of  the  scar 
tissue,  and  transplantation  and,  even  lengthening  of  tendons,  is  of 
little  avail  when  tendons  have  sloughed. 

Myogenous  contractures  consist  of  a  shortening  of  the  muscles,  first, 
as  the  result  of  nutritional  disturbances,  and,  second,  from  pathological 
processes.  The  first  occurs  when  a  limb  is  retained  in  a  certain  posi-  ■ 
Hon  for  a  protracted  period  of  time,  the  muscles  conforming  to  the 
new  conditions.  This  obtains  as  the  resula  of  hahit  in  connection  with 
an  occupation  {hahitual  contracture) ,  such  as  a  flexion  of  the  fingers  in 
drivers,  and  adduction  and  flexion  of  the  thigh  in  persons  confined  to 
bed  for  a  long  time;  it  also  i(A\ov;r^  intentional  malposition,  such  as 
a  voluntary  talipes  equinus  to  compensate  for  shortening  during  loco- 
motion, and  is  seen  after  prolonged  immoMlization  of  a  limb  (prona- 
tion, supination,  and  flexion  of  the  forearm ;  flexion  of  the  thigh  fol- 
lowing elevation  of  the  stump  after  amputation)  or  when  the  bed- 
clothes make  pressure  for  a  long  time  on  the  feet  of  a  bedridden 
patient. 

The  second  form  is  caused  by  pathological  cha^iges  in  muscles.  At 
first  the  muscle  becomes  shortened  and  rigid  because  stretching  and 
motion  are  painful.  This  occurs  in  muscular  rheumatism  of  the  neck 
and  causes  rheumatic  wry  neck,  which  soon  disappears.  In  suppurative 
myositis,  however,  and  in  muscle  tuberculosis,  syphilis,  myositis  fibrosa, 
ischemic  inflammation,  and  in  contusions  and  lacerations  of  muscles 
connective  tissue  shrinkage  soon  becomes  manifest.  Conditions  of  this 
sort  are  commonly  found  in  contractions  of  the  fingers  after  phlegmon 
of  the  flexor  side  of  the  forearm ;  in  flexion  contracture  of  the  thigh 
following  tuberculous  spondylitis  and  consequent  contraction  of  the 
degenerated  psoas  muscles;  in  the  classic  claw  hand  after  ischemic 
paralysis  of  the  muscles  of  the  forearm ;  and  in  cicatrical  wry  neck 
which  follows  laceration  of  the  sternomastoid  muscle  during  childbirth 
or  is  caused  by  fibrous  myositis. 

The  milder  forms  of  the  affliction  are  amenable  to  massage  and  pass- 
ive motion  together  with  mechanotherapy .  In  severe  cases  in  which 
forcihle  stretching  under  narcosis  is  not  effective,  elongation  of 
tendons,  tenotomy,  tendon  transplantation,  and,  at  times,  resection  of 
hones  must  be  resorted  to.  During  active  myositis  contracture  may  be 
obviated  by  fixation  in  an  overcorrected  position  until  the  process 
subsides.  In  ischemic  contractures  transplantation  of  the  nerve  may 
prove  of  benefit  (Hildebrand^). 

Neurogenous  contractures  are  associated  with  shortening  of  muscles, 


DISEASES  OF  JOINTS  1043 

which,  however,  are  due  to  lesions  of  the  nervous  system.  They  are 
divided  into  reflex,  spastic,  and  paralytic  forms. 

Reflex  contractures  are  due  to  irritation  of  sensory  nerve  fibers; 
they  attend  all  kinds  of  painful  lesions  and  are  often  the  only  indi- 
cation of  their  presence.  In  inflammations  of  joints  the  limb  is  main- 
tained in  the  posture  which  provokes  the  least  pain  and  is  fixed 
in  this  position  by  reflex  tension.  For  the  same  reason  the  abdom- 
inal wall  assumes  a  board-like  rigidity  at  the  outset  of  acute  peri- 
tonitis, and  abdominal  respiration  is  abolished ;  the  head  is  held  ri^d 
when  the  soft  parts  of  the  neck  are  inflamed,  and  the  jaw  is  rigid  when 
the  muscles  of  mastication  are  involved.  The  reflex  rigidity  of  flat 
foot  is  explained  on  the  same  basis.  At  times,  the  presence  of  a 
foreign  body  in  a  nerve,  or  the  pressure  of  scar  tLssue  following  its 
laceration,  causes  contractures. 

Removal  of  the  cause  of  contractures  of  this  sort  is  followed  by  their 
disappearance.  Prolonged  persistence  of  the  cause  is  followed  by 
shortening  and  shrinkage  of  the  muscles,  which  must  be  treated  in 
the  same  way  as  mj^ogenous  contractures.  Purely  reflex  contractures, 
without  shortening,  are  easily  corrected  under  narcosis,  when  the  part 
may  be  maintained  in  the  corrected  position  by  suitable  apparatus. 

Spastic  contractures  are  caused  by  abnormal  innervation  or  by 
pathological  irritation  of  motor  nerve  fibers  (Hofi'a^)  ;  they  may  be 
uni-  or  bilateral  and  are  almost  always  due  to  a  central  lesion.  They 
form  a  part  of  the  picture  of  the  many  lesions  of  the  brain  and  spinal 
cord  (cerebral  tumors  and  hemorrhages,  multiple  cerebral  sclerosis, 
hydrocephalus,  compression  myelitis,  spinal  sclerosis,  chronic  menin- 
gitis, hj'steria,  etc.)  or  of  congenital  spastic  paralj'sis  and  defects  and 
birth  injuries  of  the  brain.  (The  spastic  contracture  of  fingers  in 
writer's  cramp  is  really  neurosis.)  The  muscles  are  in  a  state  of 
pathological  tension  and  of  motor  feebleness  which  permits  division 
into  spastic  and  flaccid  paralysis.  They  are  hard,  are  passively 
stretched  with  considerable  difficult}^,  and  immediately  contract  when 
the  tension  is  released.  The  tendon  reflexes  are  lessened.  In  congeni- 
tal spasticity,  the  legs  alone  are  often  involved  and  are  held  rigid  by 
the  contraction  of  the  flexors  and  adductors.  The  talipes  equinus 
position  of  the  feet,  flexion  of  the  knee  and  hip  and  adduction  of  the 
thigh  makes  locomotion  difficult,  and  imparts  to  it  a  peculiar  character 
quite  indicative  of  the  condition  under  consideration  (spastic  gait). 
Each  voluntary  motion  is  attended  with  contraction  of  other  groups 
of  muscles.    In  severe  cases  locomotion  is  not  possible. 


1044    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

The  ireatvnent  (in  severe  cases),  recommended  by  Forster*,  con- 
sists of  lessening  the  reflex  are  by  resection  of  a  part  of  the  sensory 
roots  (when  the  legs  are  involved,  the  2d,  3d,  4th,  and  5th  lumbar, 
and  the  2d  sacral,  and  when  the  arms  are  involved,  the  4th,  5th,  7th, 
and  8th  cervical  and  1st  dorsal  are  divided),  to  accomplish  which  the 
spinal  canal  and  the  dura  must  be  opened.  When  only  certain  groups 
of  muscles  are  affected,  incomplete  resection  of  their  motor  supply 
may  be  accomplished  by  exposing  the  main  nerve,  isolating  the  bundle 
of  fibres  enervating  the  affected  group  of  muscles  and  sectioning  them 
by  means  of  the  electric  needle.  The  measure  is  said  to  be  followed 
by  relief  (StoffeP).  The  antagonistic  muscles  are  subjected  to  mas- 
sage and  electrotherapy.  Tenotomy  and  tendoplasty  do  not  afford 
relief.    Mechanicotherapy  is  of  use  only  in  mild  cases 

Paralytic  contractures  are  most  frequently  caused  by  anterior  polio- 
myelitis, by  injuries  of  peripheral  nerves,  by  neuritis,  and  by  various 
pathological  processes  in  the  brain  and  spinal  cord.  The  condition  is 
expressed  by  flaccid  paralysis  of  isolated  groups  of  muscles,  by  elastic 
shortening,  and,  later  (from  disuse),  by  atrophy  of  the  unparalyzed 
(antagonistic)  muscles  (Seeligmiiller's*^  antagonistic  mechanical 
theory)  ;  or  the  affected  part  presents  malposition  due  to  its  weight 
and  in  accord  with  its  residual  function.  For  instance,  paralysis  of 
the  extensors  of  the  foot  is  followed  by  talipes  equinus  from  contrac- 
tion of  the  muscles  of  the  calf  and  the  weight  of  the  foot.  On  the 
other  hand,  in  paralysis  of  the  flexors,  the  latter  may  prevent  the 
occurrence  of  talipes  calcaneus. 

The  etiology  of  anterior  poliomyelitis  is  not  clear.  Its  onset  is 
usually  sudden ;  convulsions  and  fever  may  or  may  not  occur.  In  most 
cases  the  muscles  of  the  extremities  (rarely  the  trunk)  are  affected, 
though  complete  paralysis  is  finally  restricted  to  groups  of  muscles.. 
Disturbances  of  sensation  and  of  the  bladder  and  rectum  usually  are 
absent.  Tendon  reflexes  are  diminished  and  may  be  absent.  The 
changes  in  the  cord  are  most  marked  in  the  lumbar  and  cervical  en- 
largements and  usually  consist  of  degeneration  of  the  anterior  horn, 
from  which  the  process  usually  extends  to  the  anterior  root,  the  nerve 
and  the  muscle. 

The  paralysis  most  often  involves  a  lower  extremity,  less  frequently 
both,  and  very  rarely  the  leg  and  arm  on  the  same  or  opposite  sides. 
The  muscles  of  the  lower  leg  and  forearm  are  most  often  paralyzed  and 
are  responsible  for  pes  equinovarns,  valgus,  and  calcaneovalgus.  In 
the  forearm,  flexion  contractures  predominate. 


DISEASES  OF  JOINTS  1045 

The  treatment  of  paralytic  contractures  consists  of  prolonged  mas- 
sage and  galvanism,  active  and  passive  motion,  warm  haths,  and  i7i- 
unctio7is.  Deformity  may  be  obviated  by  the  use  of  appropriate  cor- 
rective apparatus. 

When  certain  muscles  are  paralyzed,  supporting  apparatus  may  be 
employed.  In  some  cases  joints  may  be  artificially  ankylosed  (arthro- 
desis, see  operations  on  joints  Part  IV,  chapter  vii)  with  the  view 
of  improving  the  function  of  the  entire  part.  In  selected  cases  nerve 
anastomosis  may  be  employed  (Spitzy'^). 

Arthrogenous  contractures  are  caused  by  shrinkage  of  the  soft  parts 
of  the  articidar  apparatus  (synovia,  capsule,  ligaments,  and  periar- 
ticular tissues)  following  injuries  and  inflammatory  processes.  In 
inflammatory  cases,  the  contracture  is  primarily  reflex  and  myogenous, 
later  it  becomes  arthrogenous.  In  traumatic  cases,  arthrogenous  con- 
tractures are  sequential  to  prolonged  immobilization. 

Ankylosis. —  Ankylosis  always  attends  arthrogenous  contractures 
and  is  produced  in  various  ways.  (1)  The  shrinkage  of  the  capsule 
alone  may  cause  ankylosis;  (2)  as  in  all  forms  of  contracture,  con- 
nective tissue  proliferation  occurs  in  all  immobile  joints  and  solders 
the  cartilages  together  or  binds  the  bones  in  apposition  with  each 
other  when  the  cartilage  is  destroyed.  From  this  fihrous  intercartila- 
ginous  ankylosis  the  condition  merges  into  hony  ankylosis  {anliylosis 
fibrosa  inter cartilaginea  or  interossea),  which  follows  destruction  of 
the  cartilages  or  is  the  result  of  the  formation  of  a  bony  bridge  between 
the  ends  of  the  bone. 

The  treatment  of  arthrogenous  contractures  depends  upon  the  de- 
gree of  ankylosis.  In  fibrous  and  capsidar  ankylosis  the  malposition 
may  often  be  overcome  by  the  use  of  extensive  apparatus  and  pa.ssive 
motion.  In  traumatic  ankylosis,  in  which  inflammatory  reaction  is 
not  to  he  feared,  forcible  correction  under  narcosis  may  be  employed. 
The  measure  must  be  promptly  followed  by  mechanicotherapy  (the 
Zander  and  Krukenberg  apparatus). 

In  immovahle  fihrous  ankylosis  the  joint  is  opened  and  the  con- 
nective tissue  masses  carefully  and  completely  dissected  out.  Here, 
too,  the  prompt  use  of  mechanicotherapy  is  essential. 

Bony  ankylosis  .may  be  mobilized  by  osteotomy,  hy  wedge  or  bow 
shaped  resection  and  by  atypical  arthrectomy.  Flail  joints  may  be 
avoided  b}''  refraining  from  too  radical  procedures.  Early  passive 
motion  does  n©t  succeed  in  preventing  reformation  of  osseous  ankj^- 
losis.     To  avoid  this  the  interposition  of  various  substances  has  been 


1046     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

employed.  VemeuiP  uses  a  portion  of  the  joint  capsule;  Helferieli^ 
and  Lentz^"  use  a  flap  fashioned  from  a  contiguous  muscle ;  Murphy^' 
interposes  a  free  or  pediculated  fascial  transplant;  Weglowski/'  the 
cartilage  of  a  rib;  Lexer,"  an  articular  cartilage,  and  Hoffmann,^*  a 
free  periosteal  flap.  The  use  of  heterogenous  substances,  such  as  metal 
plates,  celluloid,  rubber,  etc.,  is  not  satisfactory. 

In  joints  in  which  function  is  more  or  less  dependent  upon  accurate 


Fig.   511. Dieffenbach 's   Tenotome  and  Subcutaneous   Tenotomy   of  the 

Tendon  Achillis. 


coaptation  of  joint  surfaces,  the  ends  of  the  bones  must  be  shaped  to 
conform  to  this  contingency,  and  these  are  best  kept  from  becoming 
again  adherent  by  the  interposition  of  pediculated  fascia  and  fat; 
periosteal  or  cartilaginous  flaps.  It  is  also  possible  to  transplant  an 
entire  joint,  a  measure  successfully  executed  by  Lexer.^^  The  function 
of  atrophic  muscles  and  those  degenerated  in  the  course  of  a  suppura- 
tive inflammation  may  be  replaced  by  muscle  and  tendon  plastic  re- 
pair. See  Operations  on  Bones  and  Joints,  Part  IV,  chapter  vii. 
Of  the  operations  employed  for  the  relief  of  contractures  and  paraly- 


DISEASES  OF  JOINTS 


1047 


44 


sis  of  muscles,  tenotomy,  tendon  elangation,  shortening  and  transplan- 
tation are  the  most  important. 

TeiiotoHiif,  or  tendon  section,  in  cases  of  muscle  shortening,  may  be 
executed  siihcutan'eously  or  by  the  open  method.  Subcutaneous 
division  is  made  with  a  narrow  scapel  or  with  a  sickle  shaped  tenotome 
(Fig.  511).  The  instrument  is  introduced  at  the  posterior  edge  of 
the  stretched  tendon,  which  is  carefully  divided  in  an  outward  direc- 
tion, employing  short  strokes  for  the  purpose.  The  thumb  is  apposed  to 
the  skin  with  the  view  of  preventing  its  division  (Fig.  511).  The  pull 
on  the  tendon  causes  it  to  "give  way"  suddenly  as  the  last  few  fibers 
are  sectioned.  The  stab  wound  is  sealed.  This  teclmic  is,  at  the 
present  time,  employed  only  in  connection  with  the  tendo  Achillis,  the 

tendons  at  either  side  of 
the  popliteal  space,  and 
the  adductors  of  the 
thigh. 

Open  tenotomy,  which 
consists  of  preliminary 
exposure  of  the  tendon 
and  its  division  from  the 
periphery,  has  the  ad- 
vantage of  visualizing 
the  procedure  and  makes 
possible  the  arrest  of 
hemorrhage,  careful  sep- 
aration of  adhesions, 
and  division  of  the  con- 
tracted fascia.  The  lat- 
ter is  important  in  connection  with  operative  efforts  at  relief  of  wry 
neck. 

Tenotomy  abolishes  the  function  of  the  muscle  for  only  a  short 
period  of  time,  and  is  followed  hy  an  effusion  of  blood  w^hich  is  sub- 
sequently replaced  by  connective  tissu^e.  The  latter  fills  up  the  gap 
and  soon  restores  the  function  of  the  tendon.  Passive  motion  may  be 
begun  at  the  end  of  a  week.  The  after  treatment  must  be  assiduously 
carried  out  or  the  contracture  will  recur. 

Tendon  lengthening  is  practiced  in  connection  with  larger  tendons, 
.such  as  the  ligamentum  patellae,  tendo  Achillis,  etc.,  and  is  accom- 
plished by  midtiple  lateral  incision  and  fordhh  stretching  of  the  ex- 
posed tendon    (Fig.    512b).     Bayer^®   accomplishes   the   purpose  by 


a.  b.  c. 

Fig.  512. —  Tendon  Lengthening. 

a,  Flap  method;  &,  multiple  incision  and  stretch- 
ing method ;  c,  Bayer 's  method. 


1048     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

making  two  incisions,  one  near  the  heel  and  the  other  somewhat  higher 
up  on  the  opposite  side  of  the  tendon  (Fig.  512C).  In  severe  cases 
the  method  shown  in  Fig.  512a  (also  devised  by  Bayer^**)  must  at 
times  be  resorted  to.  It  is,  however,  desirable  to  accomplish  the  pur- 
pose by  the  more  simple  methods  described. 

Tendon  shortening  is  employed  in  cases  of  paralytic  contractures  in 
which  the  muscle  is  partially  or  completel}'  parah'zed,  with  the  view 
o/  maintaining  the  joint  in  its  proper  position.  The  tendon  maj^  be 
divided,  overlapped,  and  the  apposed  sides  held  in  place  by  suture,  or 
the  tendon  may  be  plicated  in  the  manner  shown  in  Fig.  513a  and  b 
(Lange^").  The  measure  is  of  use  in  cases  of  flail  joint  {tendon  fix- 
ation). 

Tendon  transplantation  is  emplo^-ed  in  connection  with  paralytic 
contractures,  and  is  subject  to  the  same  rules  as  those  followed  in  con- 
nection with  traumatic  cases  (Part  VIII).  It  is  often  necessary  to 
combine  it  with  tendon  lengthening  and 

shortening  in  the  same  case,  in  order  to  /^ 

achieve  correction  of  the  deformitj'  and      a 
a  useful  limb.     Examples  of  the  useful- 
ness  of  tendon   transplantation   are   as 
follows:      In    paralytic    cluh    foot    the 
tendons  of  the  paralyzed  peronei  muscles      ^ 

are  divided  and  their  peripheral   ends 

T   .      ,,       p  .        ,.        .       ,        Fig.    513. —  Tendon   Plication 

anastomosed  to  the  lunctionatmg  tendo  (Lange). 

Achillis;    in    paralytic    flat    foot    the 

peripheral  end  of  the  tibialis  anticus  is  fastened  to  the  tendon  of  the 

unaffected  extensor  hallucis  longus.    F.  Krause^**  separated  the  flexor 

tendons  of  the  leg  from  their  origin  and  fastened  them  to  the  patella 

in  a  case  of  paralysis  of  the  quadriceps  extensor  muscle.     The  result 

was  encouraging.     In  a  ease  of  paralysis  of  the  radial  nerve,  Hoffa^ 

transplanted  the  insertion  of  the  flexor  carpi  radialis  and  ulnaris  into 

the   tendons   of   the  paralj'zed    extensor  muscles   with   a   successful 

outcome. 

In  all  cases  the  tendons  must  be  fixed  under  strong  tension  so  as 
to  hold  the  limb  in  an  overcorrected  position.  After  repair,  the  part 
is  held  quiescent  for  four  or  five  weeks.  In  many  instances  the  degree 
of  function  obtained  in  this  way  is  very  satisfactory. 

In  some  instances  it  is  feasible  to  transplant  muscles  in  the  form  of 
pediculated  flaps;  a  measure  which  has  proved  of  considerable  value. 


DISEASES  OF  JOINTS  1049 

Hildebrand^  transplanted  a  portion  of  the  pectoralis  major  into  the 
seratus  magnus,  and  Gersuney^^  executed  a  similar  maneuver,  using 
the  trapezius  to  replace  the  deltoid. 

SPECIAL  DISEASES  OF  JOINTS 

Synovitis  Chronica  Serosa,  Hydrops  Articularis  Chronicus,  Hydrar- 
throsis.— Chronic  irritation  of  the  synovia  leads  to  serous  exudation, 
thickening  of  the  capsule,  and  proliferative  hypertrophy  of  villi,  and 
presents  the  clinical  picture  of  hydrops  articularis.  This  picture  is 
less  a  clinical  entity  than  it  is  an  expression  of  various  joint  lesions, 
such  as  occur  in  connection  with  acute  infectious  s;^*novitis,  hema- 
tomata,  chronic  articular  rheumatism,  arthritis  deformans,  foreign 
bodies,  etc.,  or  it  appears  as  the  primary  manifestation  of  a  destruc- 
tive joint  affection  such  as  tuberculosis,  syphilis,  arthritis  deformans, 
arthritis  neuropathica,  etc. 

Chronic  synovitis  usually  develops  in  a  single  joint,  especially  the 
knee,  the  elbow,  and  the  joints  of  the  foot  and  hand,  though  it  may 
appear  simultaneously  in  several  joints.  The  process  is  attended  with 
obliteration  of  the  normal  outline  of  the  joint  as  the  result  of  disten- 
tion of  the  capsule  by  serous  exudate.  This  distention  is  gradual  in 
onset,  and  is  increased  when  the  joint  is  used ;  it  often  recedes  spon- 
taneously. WTien  proliferation  of  the  capsule  dominates  the  picture, 
the  character  of  the  process  may  be  said  to  take  on  the  form  of 
chronic  articular  rheumatism ;  the  contour  of  the  joint  is  no  longer 
visible  and  palpation  reveals  the  presence  of  nodular  areas  of  thick- 
ening in  the  capsule  and  in  the  periarticular  structures. 

The  symptoms  are  usually  slight  at  fir.st,  unless  an  acute  exacerba- 
tion of  the  process  suddenly  occurs;  the  patient  simply  complains  of 
a  feeling  of  tension,  weight  or  fatigue  in  the  joint.  Later,  when  the 
process  progres.se.s,  the  stretched  capsule  and  ligaments  allow  the  ar- 
ticular surfaces  to  become  dissociated  and  a  flail  joint,  malposition  or 
articular  surfaces  (genu  varum,  valgum,  etc.),  suhluxation  or,  when 
there  is  much  thickening  of  the  soft  parts,  painful  ankylosis  is  likely 
to  develop. 

The  diagnosis  of  articular  hydrops,  of  itself,  is  not  difficult.  It  Ls 
based  on  the  chronic,  almost  painless,  course  the  disease  takes,  together 
with  changes  in  the  surroundings  of  the  joint  and  evidences  of  fluid 
in  the  joint.    Enlarged  villi  and  nodular  areas  of  thickening  are  most 


1050    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

readily  palpated  wlierL  the  effusion  has  beeu  removed,  at  which  time 
soft  crepitation  may  be  elicited  upon  motion. 

Recognition  of  the  underlying  causative  factor  is  a  more  difficult 
problem,  especially  when  the  effusion  in  the  jomt  indicates  the  be- 
ginning of  an  arthritis  and  is  not  the  result  of  it.  In  cases  of  this 
sort  subsequent  events  must  be  awaited  before  a  decision  is  permis- 
sible. 

The  treatment,  when  the  effusion  is  moderate  in  degree,  consists  of 
elastic  compression,  massage  and  passive  motion.  Large  effusions  de- 
mand aspiration.  Hildebrand-'^  follows  this  by  lavage  of  the  synovial 
sac,  first  with  saline  and  later  with  three  per  cent  carbolic  acid  solu- ' 
tion,  followed  by  immobilization  of  the  joint  for  three  days.  Subse- 
quently the  joint  is  baked,  the  part  massaged,  and  passive  motion  is 
employed.  Painful  hypertrophied  areas  of  the  synovia  may  be  re- 
moved by  the  knife. 

Chronic  Articular  Eheumatism. — Chronic  articular  rheumatism  may 
be  characterized  as  a  painful,  chronic  inflammation  of  the  capsule, 
the  periarticular  tissues,  and  the  synovia,  attended  with  contraction 
of  the  capsular  connective  tissue,  and  swelling  and  loss  of  function 
of  the  affected  joint,  all  of  which  lead  to  atrophy  of  the  articular  car- 
tilages and  the  substitution  of  connective  tissue.  In  this  w^ay  the  joint 
cavity  is  ultimately  obliterated  and  becomes  ankylosed,  while  the  con- 
tiguous muscles  and  the  capsule  atrophy,  causing  the  part  to  become 
immovably  fixed  in  a  more  or  less  faulty  position.  The  dry  form 
{arthritis  sicca),  in  which  lessening  of  synovial  fluid  attends  the 
onset  of  the  process,  is  more  common  than  so-called  h3^drarthrosis. 

A  sharply  defined  classification  of  chronic  articular  rheumatism  is 
not  possible.  The  transitional  stages  from  chronic  hydrarthrosis  to 
articular  rheumatism,  and  from  this  to  arthritis  deformans,  are  many, 
and  are  often  mistaken  for  arthritis  urica  deformans,  and  gonorrhea 
chronica ;  and,  indeed,  at  times  for  articular  tuberculosis.  In  addition 
to  this  the  term  "chronic  articular  rheumatism"  is  often  used  in  con- 
nection with  joint  affections,  the  exact  pathology  of  which  is  not  clear. 

The  etiology  of  the  disease  is  unknown.  The  causative  association 
of  the  bacillus  demonstrated  by  Schiiller^^  is  not  proved,  though  there 
would  seem  to  be  no  doubt  that  a  certain  numher  of  cases  are  due  to 
hacterial  infection.  This  view  is  supported  by  the  observation  that 
chronic  rheumatism  is  often  a  sequel  of  the  acute  form,  and  by  the 
resemblance  the  clinical  picture  of  the  former  bears  to  chronic  gonor- 
rheal joint  affections,  to  which  may  be  added  the  fact  that  the  chronic 


DISEASES  OF  JOINTS 


1051 


condition  is  often  attended  with  acute  and  subacute  exacerbations  of 
the  process.  The  causative  influence  of  wet  and  cold,  and  prolonged 
exposure  to  moisture  (especially  climatic),  and  faulty  nutrition  would 
seem  to  be  shown  by  clinical  experience. 

The  disease  is  essentally  one  of  middle  life  and  attacks  women  more 
often  than  men.  In  young  girls,  chlorosis,  and  in  older  people,  arteri- 
osclerosis, are  believed  to  have  a  causative  influence. 

As  a  rule  several  joints  are  simultaneously  affected,  though  at  times 
the  disease  is  restricted  to  a  single  joint  and  in  severe  cases  almost  all 
the  joints  of  the  body  may  be  attacked  at  one  time.  The  knee,  the 
shoulder,  and  the  joints  of  the  fingers  and  toes  are  most  often  affected. 

The  onset  of  the  disease  is 
gradual,  though  it  is  at  times 
sequential  to  acute  articular 
rheumatism  (secondary  articular 
rheumatism). 

In  accord  with  the  course  of  the 
disease,  it  may  be  divided  into 
three  forms,  the  simple,  the  severe, 
and  the  ankylosing  (Schiiller-^), 
though  of  course  one  of  these  fre- 
quently merges  into  the  other. 

The  simple  form  js  attended 
with  slight  or  moderate  pain, 
elicited  by  pressure  and  upon 
motion,  especially  after  a  period 
of  rest ;  therefore  the  pain  is  at 
its  worst  in  the  morning.  The 
thickening  of  the  capsule  and 
the  peri-articular  tissues  appears  very  slowly  and  the  manifestations 
of  the  process  come  and  go,  each  recurrence  being  attended  with 
moderate  effusion  and  swelling.  Gradually  the  motility  of  the  joint 
is  impaired  and  atrophy  of  the  contiguous  muscles  makes  the  joint 
affection  more  prominent.  Later,  the  joint  assumes  various  degrees 
of  malposition.  The  latter  is  especially  marked  in  the  joints  of  the 
fingers  and  hands.  The  enlarged  metacarpophalangeal  joints  stand 
out  prominently  against  the  emaciated  surrounding  tissues,  the  basal 
phalanx  is  usually  extended  and  the  distal  ones  flexed  and  inclined 
toward  the  ulnar  side  (Fig.  514).     Subluxation  of  the  distal  phalanx 


Fig. 


514. —  Chronic  Arthritis   of   the 
Joints  of  the  Fingers, 


1052     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

is  not  uncommon.  In  the  accessible  sectors  of  the  capsule,  areas  of 
nodular  thickening  may  often  be  palpated.  Motion  frequently  elicits 
soft  crepitation. 

In  this  form  the  process  may  remain  moderate  in  degree  or  may 
merge  into  the  more  severe. 

The  severe  form  is  characterized  by  excessive  hypertrophy  of  the 
villi,  which  take  on  the  form  of  simple  or  multiple  bulbous  enlarge- 
ments. These  bulbs  are  very  vascular,  and  at  first  consist  of  simple 
enlargements  of  normal  villi,  but  later  extend  over  the  entire  synovia, 
fill  the  entire  joint  and  distend  its  capsule.  As  the  affliction  progresses 
the  joint  becomes  painful  and  is,  at  intervals,  the  site  of  attacks  of 
acute  inflammation,  which  are  attended  with  edema,  redness,  and  fever. 
Motion  becomes  more  and  more  painful  and  restricted  as  the  capsule 
shrinks  and  merges  with  the  surrounding  tissues,  while  the  articular 
cartilages  are  gradually  invaded  by  connective  tissue  proliferation. 
At  times  the  swelling  of  the  joints  is  sufficiently  large  to  bear  consider- 
able resemblance  to  the  tumor  alhus  of  articular  tuberculosis,  when 
observed  in  connection  with  atrophy  of  the  contracted  contiguous 
muscles  (v.  Volkmann^^).  Passive  motion  often  elicits  loud,  harsh 
crepitus.  When  a  number  of  joints  are  involved,  patients  become  bed- 
ridden and  not  rarely  die  from  exhaustion. 

In  the  third  form,  that  of  arthritis  chronica  rheumatica  ankylo- 
poetica,  the  highest  degree  of  the  affliction  is  presented.  It  is  not 
preceded  by  intermediate  degrees  of  the  process,  but  begins  at  once 
with  shrinkage  and  thickening  of  the  capsule,  while  the  articular  car- 
tilages are  promptly  destroyed  by  the  activities  of  proliferating  con- 
nective tissue,  which  also  invades  and  destroys  the  contiguous  joint 
surfaces.  This  form  of  connective  tissue  ankylosis  is  attended  with 
contractural  maljjositions  and  is  often  followed  by  bony  ank^-losis. 

A  special  form  of  chronic  arthritis,  which  attacks  the  vertebral  col- 
umn, extends  progressively  from  below  upward,  is  associated  with 
lesions  of  the  larger  joints,  and  is  described  by  Striimpel  and  P. 
Marie-^  under  the  name  of  chronic  ankylosing  spondylitis.  This 
affliction  is  probably  identical  with  that  observed  by  Bechterew,^* 
v»rhich  he  describes  as  attended  with  symptoms  of  pressure  upon  the 
spinal  nerves  (neuralgia,  atrophic  paralj'sis  of  the  muscles  of  the 
extremities)  and  ankylosis  of  the  intervertebral  articulations. 

Anatomical  investigation  would  seem  to  show  that  these  forms  of 
spondylitis  are  due  to  the  same  underlying  causative  factor;  namely, 
an  arthritis  of  the  intervertebral  joints  which  leads  to  ankylosis  (E. 


DISEASES  OF  JOINTS  1053 

FraenkeP^).  As  the  occasional  occurrence  of  periosteal  thickening  in 
these  cases  is  secondary  to  arthritis,  the  affliction  is  properly  classified 
with  arthritis  chronica  ankylopoetica  and  not  with  arthritis 
deformans. 

The  cure  of  chronic  articular  rheumatism  is  not  to  be  expected. 
Even  the  mildest  forms  remain  lifelong  afflictions.  Persistent  treat- 
ment may  and  does  make  life  bearable  and  useful,  unless  the  case  is 
one  of  the  severe  forms  involving  a  number  of  joints. 

The  differential  diagnosis  between  chronic  articular  rheumatism, 
gonorrheal  arthritis,  gouty  arthritis,  and  arthritis  deformans  is  not 
always  possible,  and,  at  times,  articular  iulerculosis  also  presents 
difficulties  in  this  connection. 

The  treatment  of  chronic  articular  rheumatism  belongs,  to  a  con- 
siderable extent,  to  internal  medicine.  Improvement  follows  the 
administration  of  the  salicin  preparations  and  the  use  of  hydrotherapy 
(steam,  mud  baths,  Fango  treatment),  massage,  gymnastic  exercises, 
and  a  more  or  less  frequent  sojourn  at  the  baths  of  Europe  and 
America. 

Bier's  stasis  hyperemia  (p.  249)  lessens  pain  and  favors  absorption 
of  connective  tissue.  This  treatment,  varied  with  the  use  of  hot  air, 
makes  a  useful  combination.  Biidinger-*'  reports  favorably  on  the 
injection  of  1  to  4  c.cm.  of  sterile  vaselin  into  the  joints ;  the  patient 
is  narcotized  during  the  procedure.  Inflation  of  the  joint  cavity  with 
oxygen  has  proved  of  service  in  the  hands  of  Eauenbusch-^. 

Contractures  may  be  corrected  by  the  use  of  extension  apparatus  or 
they  may  be  forcibh^  overcome  under  narcosis.  Painful  joints  should 
be  immobilized  in  gjjpsum  with  the  view  of  obtaining  anJiylosis  in  a 
useful  position.  In  other  joints  an  effort  should  be  made  to  restore 
mobility  of  the  part.  A  certain  degree  of  usefulness  may  be  attained 
by  the  use  of  apparatus.  Ankylosis  in  a  faulty  position  justifies 
resection.  Massive  hypertrophic  areas  of  the  capsule  and  the  villi 
may  be  excised. 

Arthritis.  Osteo-arthritis  Chronica  Deformans. —  Chronic  deforming 
inflammation  of  joints  is  the  outcome  of  a  combination  of  processes 
which  result  in  a  condition  dissimilar  to  chronic  articular  rheumatism, 
but  which  at  first  bears  a  close  clinical  resemblance  to  it.  While  it  is 
true  that  arthritis  deformans  is  also  attended  with  thickening  and 
proliferation  of  the  joint  capsule  and  the  formation  of  villosities,  it  is, 
however,  characterized  by  the  predominance  of  changes  in  the  carti- 
lages and  hones  in  which  atrophy  and  proliferation  go  hand  in  hand. 


1054    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

and  by  the  absence  of  the  formation  of  adhesions  between  the  joint 
surfaces. 

In  arthritis  deformans  the  articular  cartilages  undergo  insular  soft- 
ening and  fihrillation  and  become  fissured,  especially  where  the  joint 
is  subjected  to  pressure,  so  that  the  underlying  bone  is  exposed.  These 
exposed  areas  are  usually  worn  smooth  by  the  motions  of  the  joint. 
Presentl}'  the  nodular  masses  at  the  edges  of  the  joint  surfaces  are 
converted  into  ecchondroses,  which  later  become  more  or  less  ossified 
and  are  not  infrequently  separated  into  their  attachments,  forming 
free  joint  bodies.  The  bones  contiguous  to  the  joints  undergo  pro- 
gressive absorption,  while  the  fat  in  the  marrow  gradually  disappears 
and  is  replaced  by  a  gelatinous  material  which  often  becomes  fluid  and 
takes  on  the  form  of  cysts  (Ziegler-®).  In  this  way  the  spongiosa 
lying  beneath  the  cartilages  loses  its  resistance  and  when  subjected  to 
the  w^eight  of  the  bod}'  gradually  flattens  out.  At  the  same  time 
proliferation  of  the  periosteum  near  the  joint  takes  place  in  the  form 
of  large  nodular  areas  of  thickening  at  the  edge  of  the  affected  articu- 
lation. To  these  changes  are  added  those  occurring  in  the  capsule, 
which  consist  of  connective  tissue  thickening,  the  deposit  of  bony 
plates  and  spicula,  and  the  formation  of  numerous  villosities  on  its 
inner  aspect.  The  latter  consist  in  part  of  connective  tissue  or  are 
lipomatous  or  cartilaginous  in  character.  The  villosities  also  form 
free  bodies. 

As  the  result  of  these  processes  the  joint  undergoes  marked  changes. 
The  articular  ends  of  the  bones  are  flattened  and  widened  and  present 
nodular  protuberances;  the  joint  surfaces  become  shallow  and  are 
covered  with  grooves  and  depressions  interspersed  with  glistening, 
smooth  areas,  while  the  joint  cavity  is  filled  with  numerous  free  or 
pediculated  joint  bodies  (p.  760). 

However,  many  years  pass  before  the  process  reaches  the  degree 
stated;  the  course  of  the  disease  is  very  gradual  but  is  relentlessly  pro- 
gressive in  character.  There  are  stationary  periods,  but  recession 
toward  the  normal  practically  never  occurs. 

The  hip  and  knee  joints  are  most  often  affected  and  then,  in  order  of 
frequency,  the  elbow,  the  wrist,  the  shoulder,  the  ankle,  the  spinal 
column,  and  the  finger  joints.  The  disease  may  be  confined  to  a  single 
(especially  a  large)  joint  or  may  attack  several  at  a  time.  It  occurs 
most  often  in  the  male  sex,  usually  in  middle  life,  though  youth  is  not 
entirely  exempt.  Ost co-arthritis  deformans  juvenilis  presents  a  special 
clinical  picture  (Perthes^®). 


DISEASES  OF  JOINTS  1055 

The  causation  of  arthritis  deformans  is  still  in  obscurity.  Trauma 
and  the  constitutional  diseases  already  enumerated  in  connection  with 
articular  rheumatism  are  generally  regarded  as  causative  factors. 
Wollenberg^"  considers  that  perhaps  obliteration  of  the  arteries,  which 
intluences  nutrition,  may  be  responsible  for  degeneration.  Axhausen,^' 
after  elaborate  experimentation,  suggests  that  the  irritation  sequential 
to  focal  lesions  of  bone  and  cartilage  has  a  causative  influence ;  a  notion 
that  encompasses  as  etiological  factors  the  entire  field  of  infectious 
processes  from  which  hematogenous  lesions  of  bone  and  cartilage  might 
arise. 

Malum  senile,  a  chronic  joint  affection  seen  in  old  persons,  occurs 
chiefly  in  the  hip,  the  shoulder  and  the  elbow  joints,  and  differs  from 
arthritis  deformans  in  the  absence  of  proliferation  of  bone  and  car- 
tilage. Atrophy  of  the  affected  joint  is  due  to  senile  nutritional  dis- 
turbances and  is  characterized  by  Ziegler-^  as  arthritis  ulcerosa  sicca; 
the  capsule  is  thickened  and  the  villi  are  hypertrophied.  Similar 
changes  are  observed  in  the  joints  of  old  persons  after  prolonged 
immobilization. 

The  onset  of  arthritis  deformans  is  very  gradual.  For  a  long  time 
its  manifestations  are  restricted  to  indefinite  pain,  moderate  in  degree, 
creaking  and  crepitation  on  motion,  and  a  feeling  of  stiffness  which  is 
especially  noticeable  after  periods  of  inactivity  and  which  disappears 
soon  after  the  joint  is  used.  From  time  to  time  serous  exudates  make 
their  appearance.  These  are  often  the  first  indication  of  the  process 
and  are  indicative  of  the  presence  of  free  bodies  which  irritate  the 
synovia.  Gradually  the  contour  of  the  joint  is  changed  by  the  swell- 
ing of  the  thickened  capsule  and  the  irregular  enlargement  of  the  ends 
of  the  bones.  As  the  process  in  the  joint  surfaces  progresses,  its 
function  becomes  more  and  more  impaired.  On  the  other  hand,  the 
progressive  destruction  of  the  various  structures  of  the  joint,  especially 
of  the  cartilages  and  bones,  causes  the  limb  to  assume  abnormal  posi- 
tions (such  as  genu  valgum,  varum,  etc.).  In  this  way  the  condition, 
despite  shrinkage  of  the  capsule,  becomes  one  of  flail  joint  and  finally 
presents  the  picture  of  pathological  suhlnxations  and  dislocations. 
Despite  the  progressive  character  of  the  affliction,  it  does  not  involve 
danger  to  life. 

The  diagnosis  of  arthritis  deformans,  aside  from  the  thickening  of 
the  capsule,  is  based  on  the  serous  exudate,  the  creaking  and  crepita- 
tion upon  motion,  the  palpahle  proliferation  of  hone  and  cartilage  at 
the  edge  of  the  joint  surfaces,  and  on  the  presence  of  free  bodies.     At 


1056     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

first  the  disease  bears  a  close  resemblance  to  the  early  stages  of  chronic 
articular  rheumatism,  especially  when  several  joints  are  simultane- 
ously attacked.  Neuro^Dathic  joints  are  differentiated  by  their  asso- 
ciation with  the  causative  lesion  of  the  nervous  system.  Ankylosed 
and  severely  affected  joints  bear  some  resemblance  to  joint  tubercu- 
losis. 

The  treatment  is  carried  out  in  much  the  same  way  as  in  cases  of 
chronic  articular  rheumatism.  The  contractures  of  the  capsule 
respond  readily  to  forcible  stretching  and,  when  only  a  single  joint  is 
involved  and  there  is  considerable  change  in  the  bones,  resection  gives 
good  results.  By  the  latter  procedure  much  motility  may  be  imparted 
to  the  hip  and  to  the  joints  of  the  arms.  In  the  knee  and  ankle,  bony 
ankylosis  in  useful  positions  is  attained  with  comparative  ease.  In 
old  persons,  wnth  much  deformity  and  great  pain,  amputation  is 
justifiable. 

Special  symptoms  are  provoked  by  the  presence  of  joint  mice,  or 
joint  bodies  {corpora  libera).  These  are  free  bodies  in  joints,  which 
originate  as  the  result  of  the  separation  or  breaking  ojf  of  fibrous 
(later  calcified)  cartilaginous  villi,  of  cartilaginous  or  bony  areas  of 
proliferated  capsule,  and  of  ecchondroses.  Free  bodies  remain  quies- 
cent in  the  many  grooves  and  fissures  of  the  joint  or  move  about  in  it. 
At  times  they  remain  attached  to  the  joint  surface  or  the  synovia  by 
means  of  slender  pedicles.  These  bodies  are  frequently  present  in 
eases  of  arthritis  deformans ;  however,  in  instances  in  which  the  patho- 
logical process  in  the  joint  is  limited  in  extent  they  may  play  the  most 
important  part  in  the  clinical  picture.  Again,  free  bodies  may  be 
present  in  joints  that  do  not  manifest  the  least  evidence  of  arthritis 
deformans,  nor  of  previous  trauma.  To  this  class  of  cases,  the  path- 
ology of  which  is  not  clear,  Koenig^^  has  applied  the  term  osteo- 
chondritis desiccans.  Koenig^-  and  RiedeP^  suggest  that  the  bodies 
are  really  separated  segments  of  the  articular  cartilage  and  under- 
lying bone  which  are  exfoliated  into  the  joint  (osteochondrolysis  of 
W.  Miiller^*).  The  separated  portion  of  bone  retains  its  vitality  for 
a  long  time  and  is  even  capable  of  nodular  proliferation.  It  is  per- 
fectly possible  that  free  bodies  owe  their  origin  to  moderate  trauma 
with  subchondral  effusion  of  blood  and  subsequent  separation  of  the 
injured  area. 

Pathological,  or  arthritic  joint  mice  (Fig.  515)  differ  from  the 
traumatic.  The  former  have  a  mulberry  appearance  which  is  due  to 
the  proliferation  of  cartilage  surrounding  a  bony  nucleus,  while  the 


DISEASES  OF  JOINTS 


1057 


latter  are  smooth.  The  pathological  variety  consists  of  hyalin  and 
fibruus  cartilage,  calcified  cmmecilve  tissue,  and  bone,  the  last  often 
forming  the  nucleus.  When  microscopical  examination  reveals  normal 
joint  structure,  it  is  fair  to  assume  the  existence  of  a  traumatic  causa- 
tion. Joint  mice  may  be  single  or  multiple  and  may  vary  in  size  from 
a  pea  to  an  English  walnut. 

Their  presence  in  a  joint  causes  severe  pain  which  often  appears 
suddenly  and  is  followed  by  serous  exudation,  a  sequence  of  events 
frequently  seen  in  connection  with  the  knee  joint.  The  sudden  occur- 
rence of  severe  pain  and  locking  of  a  joint  is  quite  diagnostic  of  joint 
mouse  (so-called  mouse  symptom).     The  sudden  arrest  of  motion  is 

due  to  impaction  of  the 
free  body  between  the 
joint  surfaces  while  the 
limb  is  in  a  certain 
position. 

The  knee,  elbow,  and 
hip  joints  are  most 
often  affected,  usually 
in  muscular  meti  in 
middle  life. 

The  diagnosis  is 
based  on  the  history  and  may,  at  times,  be  verified  by  palpation  of  the 
free  body.  Unless  the  body  is  made  up  entirely  of  fibrous  tissue  or 
cartilage,  the  X-ray  will  reveal  its  presense.  Care  should  be  taken 
not  to  mistake  a  sesamoid  bone  for  a  free  body. 

The  treatment  aims  at  removal  of  the  offending  body.  As  a  rule, 
this  may  be  accomplished  through  a  small  incision  in  the  capsule, 
unless  there  are  many  free  bodies  present,  when  it  becomes  necessary 
to  open  widely  the  joint.  If  the  body  slips  into  an  inaccessible  part 
of  the  joint  during  the  operation,  pressure  should  be  made  and  the 
limb  postured  in  accord  with  the  position  which  gave  rise  to  the 
symptoms,  measures  which  usually  deliver  the  body  into  the  wound. 
After  suturing  the  capsule,  the  joint  is  immobilized  for  one  week. 
Neuropathic  Arthritis. —  Neuropathic  arthritis  bears  considerable 
resemblance  to  arthritis  deformans.  It  occurs  in  connection  with 
tabes  dorsalis,  syringomyelia,  multiple  sclerosis  and,  occasionally,  is 
secondary  to  compression  and  injury  of  the  spinal  cord,  rheumatism, 
and  laceration  of  peripheral  nerves.  However,  the  degree  of  destruc- 
tion, the  atrophy  and  hypertrophy  are  much  greater  than  obtains  in 


Fig. 


515. —  Free  Bodies  Kemoved  from  a  Knee  in  a 
Case  of  Arthritis  Deformans. 


1058     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


its  allied  disease  and  the  course  of  the  affliction  is  much  more  rapid ; 
factors  which  impelled  Schuchardt^'  to  characterize  the  process  as  "  a 
caricature  of  arthritis  deformans." 

The  clinical  manifestations  are  often  acute  in  onset  and  follow 
exertion  or  moderate  trauma. 
They  consist  of  serous  exu- 
dation and  extensive  peri- 
articular, very  tense,  edema, 
which  appear  ivithout  pain. 
According  to  Charcot,^** 
cases  of  moderate  degree  are 
attended  with  slight  changes 
hi  the  bone  and  cartilage, 
while  in  severe  cases  the  en- 
tire articular  apparatus  is 
rapidly  involved.  This  con- 
sists either  of  atrophy  of  the 
ends  of  the  bones  or  of  nodu- 
lar hyperplasia  of  the  cap- 
sule and  its  surroundings, 
together  with  the  develop- 
ment of  fiail  joints,  malpo- 
sitions, and  the  extensive 
deposit  of  new  hone  (Fig, 
516).  As  time  goes  on, 
serous  and  Moody  exudations 
appear,  the  soft  parts  he- 
come  edematous,  free  hodies 
are  separated,  spontaneous 
fractures  occur,  and  suh- 
luxations  develop.  Aside 
from  cATidenee  of  the  under- 
lying cause,  the  picture  as 
a  whole  differs  from  ar- 
thritis deformans  only  with 
regard  to  the  extent  and 
rapidity  of  the  process, 
and,   perhaps,   in   the   predominance   of  bony   growths    (Fig.   517) 

Neuropathic  arthritis  occurs  most  often  in  tabes  dorsalis  and  in 


Fig.  516. —  Arthritis  Neurcpathica  (Tabica) 
OF  THE  Right  Knee  and  Ankle  Joints. 


DISEASES  OF  JOINTS 


1039 


volves  most  frequently  the  knee  and  hip  joints.  It  is  at  times  observed 
in  the  joints  of  the  upper  extremities  in  connection  with  gliomatous 
changes  of  the  upper  segment  of  the  cord  {si/ringomyelia).  As  a 
rule,  the  process  is  unilateral,  but  at  times  it  involves  similar  joints  in 
hoth  limbs. 

Its  causation  is  attributed  to  a  combination  of  trophic  disturbances, 
anesthesia  and  analgesia  of  the  bones  and  joints,  friabilit}'  of  the 
bones,  and  mechanical  influences.  The  last  occur  to  a  marked  degree 
as  the  result  of  the  forceful  impact  peculiar  to  the  tabetic  gait. 

The  treatment  is  similar  to  that  of  anthritis  deformans,  except  that 
resection  is  not  likely  to  be  crowned  with  success  because  of  the 


Fig.  517. —  Pathological  Changes  in  Elbow  Joint  in  a  Case  of  SYaiNGOiiYELiA. 
Healed  Fracture  of  the  Ulna. 


friability  of  the  bones.  The  artful  application  of  supporting  appa- 
ratus gives  astonishing  comfort  and  makes  function  possible  in  many 
cases.  Southam^"  advocates  amputation  for  certain  cases;  he  ampu- 
tated twice  for  ankle  joint  disease,  and  twice  for  disease  of  the  tarsus ; 
in  each  instance  the  stump  healed  promptly  and  without  suppuration. 
Hysterical  Joint  (Brodie's  Joint). —  Hysterical  joint  is  generally 
described  as  a  condition  encountered  in  young  women,  involving,  as 
a  rule,  the  knee  and  hip  and  following  .slight  injury  which  acts  as  an 
autosuggestion;  a  latent  hysteria  or  neurosis  being  awakened  by  the 
trauma.  The  disease  may  ensue  upon  an  attack  of  s^Tiovitis  or 
arthritis,  or  may  arise  without  apparent  cause.  There  is  likely  to  be 
some  muscular  atrophy  from  disuse  and  the  joint  is  slightly  swollen. 


1060     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

Tlie  skin  is  hyper  esthetic  and  light  'palpation  produces  more  pain  than 
deep  pressure.  The  joint  is  usually  maintained  in  flexion,  though 
rigid  extension  is  not  infrequent,  but  the  position  is  not  one  that 
would  give  the  greatest  comfort  in  an  inflammatory  lesion.  Period- 
ical heat  of  the  surface  is  at  times  manifested,  especially  at  night,  and 
is  attended  with  apparently  very  severe  pain. 

Hysterical  phenomena  are  seldom  isolated,  but  are  associated  with 
certam  stigmata  which  may  be  latent.  These  stigmata  are  concentric 
contraction  of  the  visual  fields,  pharyngeal  anesthesia,  convulsions, 
hysterogenic  zones,  globus  hystericus,  clavicus  hystericus,  zones  of 
anesthesia,  especially  hemianesthesia,  and  hyperesthetic  areas.  As  a 
rule,  such  patients  are  predisposed  hy  inheritance  and  have  previ- 
ously exhibited  neuroses  of  various  kinds.  The  general  health  is 
usually  good,  but  neurasthenia  may  coexist.  In  examining  cases  of 
this  sort  it  is  noticeable  that  the  symptoms  disappear  when  the  atten- 
tion is  diverted,  that  they  are  out  of  all  proportion  to  the  local  evi- 
dence of  disease,  that  there  is  no  sign  of  destruction  of  the  joint,  and 
that  a  light  touch  may  cause  pain  while  none  is  elicited  by  firm 
pressure.     The  narcotic  state  permits  free  mobility  of  the  joint. 

This  is  in  substance  the  description  found  in  most  textbooks  of  so- 
called  hysterical  joint,  and  no  doubt  is  applicable  to  a  certain  number 
of  cases.  Recently,  however,  extensive  study  has  been  made  by  Henry 
Miege,  Mme.  Ath-Benisty  and  Mile.  Levy^^  in  connection  with  soldiers 
wounded  in  the  world  w^ar.  These  observers  submit  that  so-called 
hysterical  joints  are  often  due  to  reflex  disturbances,  and  quote  in 
support  of  their  contention  the  work  of  Babinski  and  Fromont,"**  whose 
studies  seem  to  justify  the  conclusion  of  Miege  and  his  collaborators. 
Benisty*°  presents  a  discussion  in  this  connection  which  is  too  com- 
prehensive to  be  repeated  here.  The  reader  is  referred  to  her  work 
(see  bibliography)  for  details.  However,  it  is  proper  to  state  here 
that  reflex  causes,  such  as  irritation  of  remote  peripheral  nerves  and 
nerve  centers,  should  be  carefully  excluded  before  a  conclusion  is  per- 
missible. This  is  especially  important  in  cases  occurring  in  soldiers 
who  may  be  unjustly  accused  of  malingering.  In  addition  to  this,  it 
is  to  be  remembered  that  contractural  fixation  of  joints  may  arise  in 
connection  w^ith  psychic  influences,  such  as  occur  when  troops  are 
under  fire,  and  that  a  critical,  to  say  nothing  of  a  brutal,  attitude  on 
the  part  of  the  attendant  is  not  of  therapeutic  value. 

Tbe  treatment  of  hysterical  joints  comprises  attention  to  the  general 
health,  the  employment  of  nourishing  and  easil}^  digested  food,  and  .the 


DISEASES  OF  JOINTS  1061 

administration  of  tonics.  The  surgeon  must  dominate  the  patient's 
mind,  though,  as  already  stated,  brutalities  should  be  avoided, 
Babniski'^'*  thinks  that  psychotherapy  is  of  help  in  the  purely  hyster- 
ical type,  but  not  when  the  condition  is  reflex  in  origin.  In  either 
event,  psychotherapy  cannot  do  harm  and  should  be  combined  with 
viassage,  haihs,  and  electrotherapy.  Under  no  circumstances  should 
the  part  be  immobilized  (Miege^^). 

Articular  Gout.  Arthritis  TJrica. —  The  clinical  picture  of  gout  is 
dominated  by  acute  and  chronic  inflammation  of  joints.  Gout  is  a 
constitutional  disease  (often  inherited)  dependent  upon  disturhances 
of  the  metaholic  processes,  which  results  in  the  deposit  of  urates  in  the 
tissues,  especially  the  joints  and  their  surroundings.  The  deposit  of 
urates  is  attended  with  the  symptoms  of  inflammation.  Chronic  alco- 
holism, high  living,  and  chronic  lead  poisoning  are  believed  to  favor 
its  development.     It  occurs  chiefly  in  men  of  middle  life. 

While  joint  lesions  are  usually  the  most  frequent  manifestation  of 
the  disease,  it  also  involves  the  vital  organs,  of  which  the  kidney 
(chronic  interstitial  nephritis)  is  the  most  important.  Kidney  and 
bladder  stones  are  not  infrequent  complications,  as  are  also  obesity, 
diabetes  mellitus,  and  arteriosclerosis. 

When  the  vital  organs  are  not  affected,  afflicted  persons  may  reach 
old  age;  when,  however,  nephritis  complicates  the  situation,  the 
prognosis  is  not  good. 

Gouty  arthritis  is,  as  a  rule,  -sudden  in  onset,  though  it  is  often 
preceded  by  prodromata  consisting  of  muscle  pain,  lassitude,  chilly 
sensations,  and  digestive  disturbances.  Fever  is  likely  to  be  slight, 
though  2^ciin  is  severe,  and  the  affected  joint,  which  is  in  a  number  of 
cases  primarily  the  metatarsophalangeal  articulation  of  the  great  toe, 
is  tender.  The  frequency  with  which  the  joint  stated  is  involved  is 
explained  on  the  ground  of  its  peripheral  location  and  its  suscepti- 
bility to  arthritis  deformans.  The  affected  joint  and  the  contiguous 
soft  parts  are  swollen  and  the  superimposed  skin  is  red,  presenting 
the  appearance  of  an  acute  suppurative  or  gonorrheal  inflammation. 
The  fever  usually  drops  with  a  profuse  perspiration  in  the  morning, 
but,  as  a  rule,  rises  again  at  night.  The  general  symptoms  are  not 
severe.  An  attack  of  this  sort  lasts  from  one  to  two  weeks  and  is 
usually  followed  by  complete  return  to  the  normal. 

When,  however,  the  attacks  are  repeated,  occurring  at  intervals  of 
several  weeks,  months,  or  even  years,  thickening  of  the  tissues  about 
the  joint  makes  its  appearance  and,  as  the  attacks  recur,  serious 


1062     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

changes  take  place  iu  the  joint  primarily  involved,  and,  to  a  certain 
extent,  in  the  other  joints  of  the  body. 

While  chronic  gout  is  usually  preceded  by  the  acute  form,  the  dis- 
ease ma}'  make  its  appearance  primarily  in  the  former  guise.  In  this 
event,  it  begins  with  mild  inflammation  of  the  part  and  progresses  by 
repeated  exacerbations.  In  all  situations  where  urates  are  deposited, 
the  capsule,  the  bone,  the  synovia,  and  the  ligaments  undergo  necrosis, 
but  the  surrounding  healthy  tissues  furnish  gramdation  tissue  which 
strives  to  destroy  or  encapsulate  the  destroyed  areas.  To  this  regen- 
erative process  may  be  ascribed  the  thickening  of  the  capsule  and  the 
stiffening  of  the  joint y  while  the  progressive  absorption  of  the  carti- 
lages and  of  the  underlying  bones  is  responsible  for  articular  malposi- 
tions and  luxations.  The  thickening  is  gradually  more  marked,  the 
deposit  of  urates  increases,  and,  after  destroying  the  capsule,  iiivades 
the  surrounding  tissues  and  finally  reaches  the  skin  and  is  deposited  in 
the  tendons,  in  the  l)ursae,  or  in  the  suhcutaneous  tissues  in  small  cir- 
cumscribed accumulations.  These  nodular  masses,  which  are  especi- 
ally noticeable  in  the  subcutaneous  tissues  in  regions  more  or  less 
remote  from  the  joints,  are  called  gouty  7iodules  or  tophi  (uratici). 
The  skin  lying  over  the  tophi  is  usually  tense  and,  not  rarely,  under- 
goes necrosis  from  within  or  from  pressure  or  a  slight  injury  from 
without,  following  which  a  fistula  is  formed.  Fistula  of  this  sort  at 
times  discharge  chalky  masses  and  not  infrequently  are  the  port  of 
entrance  of  infection  which  extends  to  the  joint. 

The  diagnosis  of  gout  is  made  certain  by  the  presence  of  tophaceous 
deposits.  Tophi  are  round,  covered  by  atrophic,  slightly  immovable 
skin,  and  may  develop  to  the  size  of  an  English  walnut  or  even  to  that 
of  a  hen's  egg.  They  are  hard  and  usually  adherent  to  the  deeper 
tissu-es,  and  are  found  in  the  vicinity  of  joints  or  on  the  backs  of  the 
hands  and  the  feet,  in  the  suhcutaneous  tissues  of  the  scalp,  where 
they  may  be  differentiated  from  multiple  gumma  of  the  periosteum 
by  their  greater  motility,  and  finallj',  not  infrequently^,  they  invade 
the  ears,  the  eyelids,  and  the  7iose,  where  usually  the}^  do  not  attain 
a  greater  size  than  that  of  a  pea.  In  the  last  three  situations  they 
may  be  Sv?en  through  the  thinned  out  skin. 

In  the  absence  of  tophi,  gout,  especially  an  acute  attack,  is  not 
always  readily  recognized.  In  this  event  the  disease  may  simulate 
acute  gonorrheal  infection,  and  clironic  gout  is  easily  mistaken  for 
chronic  articular  rheumatism.  The  absence  of  lymphatic  invasion 
should  exclude  pyogenic  infection. 


DISEASES  OF  JOLNTS  1063 

When  fistulas  are  present,  the  process  bears  some  resemblance  to 
tuberculosis,  and  at  times  the  differential  diagnosis  is  not  made  until 
the  discharge  of  chalky  masses  occurs  or  the  microscope  reveals  the 
presence  of  fine  crystals  of  urates  in  the  discharge. 

Section  of  a  gouty  joint  reveals  characteristic  pathological  changes. 
As  the  urates  are  primarily  deposited  on  the  articular  cartilages,  these 
present  a  layer  of  material  resembling  gj-psum  or  chalk.  In  time  the 
deposits  involve  the  deeper  structures,  where  they  cause  ulceration, 
which  ultimately  invades  and  destroys  the  underlying  bones.  At  the 
same  time  the  joint  is  filled  with  particles  of  a  mortar-like  substance, 
which  infiltrates  the  synovia  and  the  ligaments  of  the  joint  and  extends 
into  the  surrounding  soft  parts.  The  deposits  consist  mostly  of  sodium 
biurate. 

The  reactive  inflammatory  process  provoked  b}''  the  deposits  causes 
the  production  of  connective  tissue  proliferation,  which  is  concerned 
in  efforts  at  encapsulation  of  the  invading  foreign  material. 

The  treatmefit  of  gout  belongs,  to  a  large  degree,  to  the  department 
of  internal  medicine,  and  in  a  general  way  consists  of  a  dietetic 
regimen,  bodily  exercises,  baths,  and  water  cures  (alkaline  waters) — • 
measures  tending  to  lessen  the  production  of  urates. 

During  the  acute  attack  of  arthritis,  the  affected  limb  is  padded 
with  cotton,  immobilized  in  an  appropriate  splint,  and  postured  in  an 
elevated  position.    Morphia  and  the  salicylates  are  freely  administered. 

Moist  dressing  relieves  pain,  but  in  an  acute  attack  it  macerates  the 
skin  and  favors  the  formation  of  fistula;  therefore  it  should  be 
avoided. 

Operative  efforts  at  relief  come  into  consideration  in  connection  with 
large  tophi  of  the  soft  parts,  when  excision  is  indicated.  Amputation 
of  badh^  damaged  fingers  and  toes  is  justifiable,  especially  when  sup- 
puration supervenes.  Scraping  out  of  the  deposits  is  not  a  useful 
measure,  as  the  tissues  are  not  capable  of  regeneration  and  are  soon 
secondarily  invaded.  Complete  resection  of  tophaceous  deposits  has 
been  followed  by  an  attack  of  gout  in  the  same  situation.  However, 
RiedeP^  dissected  out  the  deposits  of  urates  and  the  capsule  of  the 
joints  of  the  big  toes  of  a  patient  who  remained  free  from  s^'niptoms 
for  one  year  and  who  then  died  of  other  causes. 

Joint  Diseases  in  Hemophilia. —  Hemophilia  is  frequently  attend^d 
with  bleeding  into  joint  cavities.  The  effusion  of  blood  imparts  a 
characteristic  clinical  picture  to  the  affected  joint. 

The  lesion  may  occur  in  children  and  may  follow  .slight  trauma  or 


1064    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

muscular  exertion.  One  or  more  joints  may  be  involved;  the  knee  is 
most  commonly  affected.  Unless  the  patient  succumbs  to  bleeding 
from  other  sources,  the  affected  joint  undergoes  severe  pathological 
changes. 

The  course  of  the  disease  may  be  divided  into  three  stages 
(Koenig*^).  The  first,  consisting  of  a  hemarthrosis,  is  manifested  by 
the  sudden  appearance  of  pain,  slight  febrile  movement,  and  fluid 
distention  of  the  joint  capsule,  which  bears  some  resemblance  to  an 
inflammatory  hydrops.  A  few  da^^s  later  the  distinctive  ecchymosis 
and  discoloration  of  the  skin  makes  the  nature  of  the  exudate  clear. 
When  the  bleeding  is  not  attended  with  changes  in  the  joint,  the 
exudate  is  entirely  absorbed  in  about  two  weeks  and  the  function  of 
the  articulation  is  resumed ;  indeed,  it  is  not  uncommon  for  several 
joints  to  be  attacked  simultaneously  in  this  way,  or  for  a  single  joint 
to  be  repeatedly  the  seat  of  a  hemorrhagic  effusion,  and  restitution  to 
the  normal  ensue.  Gocht^^  reports  a  case  in  which  hemarthrosis  of  a 
knee  joint  occurred  forty-five  times  without  any  evidence  of  impair- 
ment of  its  function. 

In  most  cases,  however,  the  disease  merges  into  the  second  stage, 
that  of  general  chronic  inflammation,  or  paiiarthritis  (Koenig*^). 
The  effusion  is  not  entirely  absorbed,  the  capsule  becomes  thickened; 
crepitation  on  motion,  pain,  impairment  of  function,  and  contractural 
malposition  indicate  changes  within  the  joint.  The  pathological 
changes,  according  to  Koenig,'*^  are  the  outcome  of  fibrin  deposits, 
which  maintain  the  joint  in  a  constant  condition  of  chronic  inflamma- 
tion and,  as  the  result  of  organization  (like  joint  tuberculosis), 
destroy  the  articular  cartilages.  Section  reveals  a  serosanguineous 
exudate;  the  capsule  is  thickened  and  hard,  the  synovial  villi  are 
brown  in  color  and  proliferated;  the  recesses  of  the  joint  and  the 
edges  of  the  cartilages  are  filled  with  accumulated  coagulum  and  the 
surfaces  of  the  cartilages  present  irregular  defects.  The  clinical  pic- 
ture is  not  readily  differentiated  from  that  of  the  granulating  form  of 
joint  tuberculosis  or  the  transitional  form  of  hydrops,  as  it  merges  into 
ihe  latter. 

The  third  stage,  that  of  regression,  leads  to  the  contractural  form 
of  bleeder's  joint  (Koenig^^).  The  organized  coagulum  forms  a 
fibrous  union  between  the  connective  tissue  of  the  eroded  joint  sur- 
faces, and  the  chronically  inflamed  capsule,  together  with  the  peri- 
articular tissues,  undergoes  contracture.  In  this  way  contractures  and 
dnkyloses  are  developed,  which  are  not  rarely  attended  with  subluxa- 


DISEASES  OF  JOINTS  1065 

tio^is.  The  contour  of  the  thickened  joint  area  stands  out  in  sharp 
contrast  to  the  conti^ous  atrophied  muscles,  but  this  is  not,  as  it 
appears  to  be,  due  to  an  increase  in  the  size  of  tlie  articular  ends  of 
the  bones  but  is  caused  by  the  thickened  capsule.  In  this  stage  the 
process  is  likely  also  to  be  viistaken  for  joint  tuberculosis. 

The  three  stages  as  described  do  not,  of  course,  occur  in  all  cases  of 
bleeder's  joint;  many  persons  spontaneously  recover  from  the  tend- 
ency to  bleed  into  the  joints  while  others  go  on  to  the  third  stage  of 
the  disease. 

The  diagnosis  is  aided  by  recognition  of  the  underlying  hemophilia. 
As  a  rule,  the  patient  is  a  pale,  young  child,  frequently  of  the  male 
sex.  Beside  joint  tuberculosis  (as  stated),  hemarthrosis  due  to  the 
intra-articular  rupture  of  myelogenous  sarcoma  must  be  taken  into 
account. 

The  treatment  is  limited  to  immohilization  and  compression  of  the 
part  by  means  of  extension  and  the  use  of  elastic  bandages  (Gocht*^). 
Forcible  correction  of  contracture  is,  of  course,  to  be  avoided.  Fatal 
bleeding  has  followed  disregard  of  this  warning.  Aspiration  fol- 
lowed by  lavage  of  the  joint  with  three  per  cent  carbolic  acid  solution 
has  proven  of  value  (Koenig*^).  The  local  and  general  employment 
of  gelatin  is  taken  up  elsewhere  (p.  43). 

Ganglion. —  Ganglion  is  a  term  applied  to  a  cystic  formation,  which 
develops  frequently  from  the  tissues  of  a  joint  capsule  or,  more  rarely, 
from  a  tendon  sheath  or  tendon. 

Joint  ganglia  are  most  often  found  on  the  dorsum  of  the  wrist  joint, 
where  they  protrude  between  the  extensor  tendons  of  the  index  finger 
and  the  tendon  of  the  radii  carpi  dorsalis  and  push  aside  the  ligamen- 
tum  carpi  dorsalis  {ganglion  carpale  dorsale).  At  times  a  ganglion 
makes  its  appearance  on  the  flexor  side  beside  the  radial  artery  next 
to  the  tendon  of  the  tlexor  carpi  radialis.  They  also  appear  on  the 
dorsum  of  the  foot  (Fig.  518),  and,  occasionally,  in  the  region  of  the 
knee  joint  and  on  the  flexor  side  of  a  metacarpophalangeal  joint. 

TTie  sac  wall  of  the  ganglion  is  formed  of  glistening  connective 
tissue  derived  from  the  capsule  and  is  filled  with  a  gelatinous,  vitreous 
fluid.  Attachment  to  contiguous  tendons  occurs  as  the  result  of  unsuc- 
cessful efforts  at  treatment.  The  cyst  is  connected  with  its  point  of 
origin  by  a  broad,  usually  short,  pedicle  and  is  separated  from  the 
joint  cavity  by  a  thin  membrane,  which  is,  however,  often  ruptured. 
Young  cysts  are  usually  multilocular,  while  older  ones  have  a  single 


1066     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

cavity  which  has  shallow  projections  on  its  interior.     The  microscope 
reveals  the  multilocular  character  of  simple  cysts. 

Ganglia  were  for  a  long  time  looked  upon  as  protrusions  of  joint 
synovia.  Investigations  made  in  connection  with  operative  measures  of 
relief  seemed  to  show  this  view  to  be  erroneous,  and  that  they  originate 
from  the  joint  capsule  itself  (Falkson  and  RiedeP^).  This  conclu- 
sion was  subsequently  shown  to  be  correct  by  the  histological  examina- 
tions of  Ledderhose,**  and  later  by  Ritsch,*'  Thorn,^''  and  Payr,*'  who 
showed  that  the  process  consists  of  a  gelatinous  degeneration  in  the 
capsule  SlU^  in  the  para-articular  (at  times, 
in  the  paratendinous  and  tendinous)  tis- 
sues, the  result  of  nutritio7ial  disturb- 
ances following  traumatic  endarteritis 
obliterans,  which  cause  the  formation  of 
hollow  spaces. 

The  cysts  usually  appear  in  early  life 
(at  about  puberty),  especially  in  girls; 
though  they  do  at  times  occur  later. 

The  symptoms  are,  at  first,  very  slight, 
consisting  of  interference  with  motion  and 
moderate  indefinite  pain.  The  patient 
often  associates  the  discomfort  with  a 
slight  sprain,  which  is  less  likely  to  be  the 
cause  than  repeated  stretching  and  over- 
exertion, such  as  occurs  in  piano  playing, 
rowing,  fencing,  etc.  When  the  ganglion 
reaches  noticeable  size,  the  diagnosis  be- 
comes clear.    Further  enlargement  of  the 

cvst  is  slow  and,  when  a  certain  size  is  „,„      « 

'  .     ,.,    T  .      Fig.   518. —  Ganglion   on   the 

reached,  the  process  is  likely  to  remain  Dorsum  of  thk  Foot. 

stationarj^     These  cysts  are  rarely  larger 

than  an  English  walnut.     Spontaneous  disappearance  of  the  smaller 

cysts  is  not  rare.    Even  in  cases  of  large  cysts,  moderate  interference 

with  motion  is  often  the  only  symptom  present. 

The  character  of  the  lesion  is  clearh^  defined.     The  superimposed 

skin  is  unchanged  and  is  freely  movable  over  the  smooth,  globular, 

sharply  outlined  tumor,  which  is  either  immovahly  attached  to  the 

deeper  structures,  or  is  slightl}'  movable.     The  consistence  of  small 

ganglia  is  hard,  the  larger  fluctuate. 


DISEASES  OF  JOINTS  1067 

The  diagnosis  is  based  on  the  clinical  picture  described,  together 
with  the  location  of  the  tumor,  which  is  important  with  regard  to 
hygroma  of  bursae  and  tendon  sheaths. 

The  treatment  aims,  primarily,  at  Moodless  healing,  which  means  the 
subcutaneous  rupture  of  the  cyst  by  a  forcible  hloiv  with  a  mallet  or 
other  blunt  object,  or  by  making  contmuous  pressure  by  means  of  a 
lead  disc  bandaged  in  place.  The  latter  method  thins  out  the  cyst  wall, 
which  ultimately  ruptures.  Mechanical  rupture,  as  stated,  is  success- 
ful in  most  cases.  Magnus*^  reports  720  cases,  102  of  which  reported  for 
subsequent  examination.  Of  these,  52  were  ruptured  subcutaneously ; 
in  23  the  cyst  returned.  Thirty-one  M-ere  excised;  of  these  none  re- 
curred. Eight  ganglia  disappeared  spontaneously,  and  10  had  no 
return  after  pressure  treatment. 

When  the  bloodless  treatment  fails,  extirpation  is  indicated,  a  meas- 
ure which  should  be  carefully  executed.  Since  complete  removal  of 
the  cyst  wall,  together  with  its  pedicle,  involves  opening  the  joint  and 
tendon  sheaths,  infection  would  be  an  exceedingly  dangerous  matter. 
Therefore,  the  operation  should  always  be  performed  with  exsangui- 
nation  of  the  part,  with  the  view  of  readily  identifying  the  various 
tissues  exposed,  and  under  no  circumstances  should  the  finger  be  intro- 
duced into  the  wound. 

Recurrence  does  not  follow^  extirpation  unless  a  portion  of  cyst  wall 
or  of  the  pedicle  is  left  behind. 

Subcutaneous  discission,  aspiration,  the  injection  of  chemical  irri- 
tants, and  incision  and  tamponade  are  uncertain  measures  of  relief. 

BIBLIOGRAPHY 

1.  HOFFA.     Lehrb.  d.  Ortliop.  Chir.,  Stutto-art,  1906. 

2.  Lexer.     Med.  Klinik,  1908,  also  Chir.  kong.  Verh.,  1909,  ii. 

3.  HiLDEBRAND.     Zentrbl.  f.  Chir.,  1905. 

4.  FoRSTER.     Mitteil  a.  d.  Grenzgeb.  Bd.  20,  1909;  also  Chir.  kong.  Vehr., 

1910;    also  Ergeb.  d.  Chir.  u.  Orth.  Bd.  2,  1911. 

5.  Stopfel.     Verh.  d.  Orth.  Gesell.,  1913,  ii. 

6.  Seeligmuller.     See  Forster  No.  4. 

7.  Spitzy.     Wien.  klin.  Woch.,  1909. 

8.  Verneuil.     See  No.  14. 

9.  Helferich.     See  No.  14. 

10.  Lentz.     See  No.  14. 

11.  Murphy.    Jr.  A.  M.  A.,  1905. 

12.  Weglowski.     Zentrbl.  f.  Chir.,  1907. 

13.  Lexer.     Med.  klinik.,  1908;   also  Chir.  kong.  Verb.,  1909,  ii. 

14.  Hoffmann.     Beitr.  z.  klin.  Chir.,  Bd.  59,  i908. 

15.  Lexer.     Surg.  Gyn.  Obst.  vi,  1908. 


1068     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

16.  Bayer.     Zentrbl.  f.  Chir.,  1901. 

17.  Lange.     Handb.  d.  Orth.  Bd.  i,  with  lit.;    also  Ergeb.  u.  Orth.  Bd.  ii, 

1911. 

18.  F.  Krause.     Deutsch.  med.  Woch.,  1902. 

19.  Gersuney.     Wien  klin.  Wocb.,  1906. 

20.  HiLDEBRAND.     Arch.  f .  klin.  Chir.  Bd.  81,  1906. 

21.  ScHULLER.     Chir.  kong.  Verb.,  1892,  ii. 

22.  V.  VOLKMANN.     V.  Pitha-Billroth's   Handb.   d.   Chir.,  Bd.   2,   Erlangen, 

1872. 

23.  StrIjmpel  and  P.  Marie.     Quoted  by  Lexer,  AUg.  Chir.  ii,  Stuttgart, 

1914. 

24.  Bechterew.     Quoted  by  Lexer,  Allg.  Chir.  ii,  Stuttgart,  1914. 

25.  E.  Fraenkel.     Fortseh.  d.  Geb.  d.  Rbntgenstrahlen,  Bd.  7,  1904. 

26.  BtJDiNGER.     Wien  klin.  Woch.,  1904. 

27.  Rauenbusch.     Zentrbl.  f.  Chir.,  1907. 

28.  ZiEGLER.     Virchow's  Arch.  Bd.  70,  1877. 

29.  Perthes.     Zentrbl.  f.  Chir.,  1908.     See  also  Eden,  Deutsch.  Zeitschr.  f. 

Chir.  Bd.  117,  1912. 

30.  Wollenberg.     Zentrbl.  f.  Chir.,  1907,  discussion  by  Hildebrand,  Koenig, 

and  others.     See  also  Atiol.  f.  Artlir.  Deform.,  Stuttsrart.  1910. 

31.  AxHAUSEN.     Arch.   f.  klin.    Chir.   Bd.   94,   1911 ;     also   Verb.   d.   Path. 

Gesell,  1912;    also  together  with  Pels,  Deutsch.  Zeitschr.  f.  Chir.  Bd. 
110,  1911. 

32.  KOENIG.     Chir.  kong.  Verb.,  1899,  ii. 

33.  RiEDEL.     Deutsch.  med.  Woch.,  1904. 

34.  W.  Muller.     Quoted  by  Koenig  No.  32. 

35.  ScHUCHARDT.     Deutsch.  Chir.,  1899,  with  lit. 

36.  Charcot.     See  Schuchardt  No.  35. 

37.  SouTHAM.     Quoted  by  Da  Costa,  Modern  Surgery,  Saunders,  1914. 

38.  Henry   Miege,    and   others.     Soc.    de   Neurol.,   1915.     See    also    Revue 

Neurol.,  1915. 

39.  Babinski  and  Froment.     Acad,  de  Med.,  1915-1916;    Soc.  de  Neurol., 

1915-1916;  Presse  medicale,  1916;  Ann.  de  Med.,  1916. 

40.  Mme.  Benisty.     Med.  and  Sure.  Therapy,  ii,  Appleton,  1918. 

41.  Koenig.     Samml.  klin.  Vortr.  N.  F.,  1892,  No.  36. 

42.  GocHT.     Chir.  Kong.  Verb.,  1899,  ii. 

43.  Falkson  and  Riedel.     See  Thorn  No.  46. 

44.  Ledderhose.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  37,  1893. 

45.  RiTSCH.     Beitr.  z.  klin.  Chir.  Bd.  14,  1895. 

46.  Thorn.     Arch.  f.  klin.  Chir.  Bd.  52,  1896. 

47.  Payr.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  49,  1898. 

48.  Magnus.     Same  as  No.  35. 


CHAPTER  VII 

DISEASES  OF  BONES 

Congenital  Defects  in  Skeletal  Development. —  Congenital  defects  in 
the  development  of  the  osseous  sj'stem  are  responsible  for  a  number  of 
malformations.  These  consist,  firsi,  of  defects  due  to  arrest  (aplasia) 
and  to  inhibition  of  development,  such  as  partial  or  complete  absence 
of  bones  of  the  extremities,  the  clavicle,  the  sternum ;  defects  of  the 
cranial  bones,  the  vertebral  arches;  and  fissures  in  the  maxilla.  To 
this  class  belong  also  the  .so-called  end  defects  of  extremities  due  to 
their  amputation  by  the  strangulation  of  amniotic  bands.  The  second 
class  of  defects  are  those  of  excessive  development,  consisting  of 
supernumerary  phalanges,  metacarpal  and  metartarsal  bones,  cervical 
ribs,  and  additional  vertebrae  (tail  formation).  The  third  class  of 
cases  include  hony  deformities  due  to  fetal  diseases  of  bones  and  in- 
tra-uterine  fractures,  and  the  various  hyperplastic  and  hypertrophic 
conditions  of  bones  which  originate  w  utero  or  develop  soon  after 
birth. 

Hypoplasia  maj-  be  manifested  by  in.sufficient  growth  of  the  entire 
skeleton,  resulting  in  a  dwarf  (microsomia) ,  or  the  extremities  alone 
may  be  involved  (micromelia),  or  it  may  be  expressed  by  congenital 
(acquired  intra-uterine)  osseous  atrophy  (so-called  fetal  rachitis).  To 
the  last  belong  the  chondral  dysplasia  (the  fetal  chondrodystrophy 
of  Kaufmann^  and  the  fetal  cretinism  of  Horsley-)  which  are  due  to 
either  arrest  of  enchondral  ossification,  characterized  by  the  formation 
of  hard,  shortened,  deformed  bones  —  the  result  of  periosteal  ac- 
tivity which  remains  normal  —  or  to  defective  periosteal  ossification 
(periosteal  dystrophy),  while  chondral  ossification  progresses  normally 
and  thus  causes  malformation  of  the  bones.  In  the  latter  form  the 
bone  is  soft  and  friable  (the  osteogenesis  imperfecta  of  Schuchardt^). 

Hypertrophy  of  the  bones  causes  general  (macrosomia)  or  partial 
giant  growth.  The  latter  is  restricted  to  the  feet  or  hands.  Congenital 
osteosclerosis  involves  the  entire  skeleton. 

The  inhibition  of  bony  growth  in  cretinism,  seen  in  endemic  form  in 

1069 


1070    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

young  persons  in  so-called  goiter  districts,  is  due,  as  are  the  other 
symptoms  (myxedema,  idiocy,  hyperplasia  of  the  genitals)  to  a  dis- 
turbance of  the  thyroid  gland,  which  is  either  absent,  atrophied  or 
altered.  This  causative  relationship  has  been  experimentally  demon- 
strated (v.  Eiselsberg^).  In  cretinism  the  epiphyseal  cartilages  remain 
intact  for  a  long  time,  but  do  not  produce  the  new  bone  necessary  to 
the  growth  of  the  individual.  Bone  cells  do  not  make  their  appear- 
ance until  later  in  life  than  is  normal.  Early  and  persistent  thyroid 
feeding  is  attended  with  improvement  of  the  general  condition  and 
some  growth  of  the  long  bones  (v.  Eiselsberg^).  Bircher-"'  seems  to 
have  shown  that  implantation  of  fresh  thyroid  tissue  does  not  ac- 
complish the  purpose. 

Atrophy  of  Bone. —  Atrophy  of  bone  is  the  result  of  lacunar  ab- 
sorption. This  absorption  is  not  in  excess  of  the  normal,  but  the 
replacement  of  bone  does  not  keep  pace  with  it,  hence  the  atrophy 
(Schuchardt^). 

At  times  the  resorption  of  bone  begins  on  its  surface  (concentric 
atrophy),  at  others,  the  medullary  canal  is  enlarged  and  the  atrophied 
areas  are  filled  with  fatty  tissue  (excontric  atrophy).  As  the  corti- 
calis  is  thinned  and  the  haversian  canals  and  the  meshes  of  the 
spongiosa  are  enlarged  (by  absorption),  the  entire  bone  becomes 
porous  and  light  {osteoporosis) ,  and  either  decayed  or  friable  {osteo- 
psathyrosis) or,  as  the  result  of  loss  of  lime,  the  bone  shows  a  ten- 
dency to  bend  {porotic  osteomalacia) . 

The  surgical  import  of  atrophy  of  bones  lies  in  their  fragility,  which 
renders  them  exceedingly  liable  to  fracture,  and  also,  because  of  the 
lack  of  callus  formation,  they  are  not  likely  to  heal.  For  the  same 
reason,  union,  following  reseotion  of  joints  where  ankylosis  is  aimed 
at,  is  not  always  obtained. 

The  causes  of  atrophy  of  bone  are  local  and  general,  of  which  the 
latter  predominate. 

The  local  causes  relate  to  aneurisms,  tumors,  and  ecchinococci,  which 
extend  to  the  bone  from  without  or  develop  within  and  destroy  the 
corticalis  {pressure  artophy).  Atrophy  is  also  caused  by  prolonged 
disuse  {disuse  atrophy).  The  last  form  attacks  the  bones  of  joints 
which  have  not  functionated  for  a  long  time,  in  connection  with 
trauma,  inflammatory  processes,  and  paralyses,  and  also  occurs  in  mis- 
placed fractures,  the  overriding  portions  of  which  are  gradually 
absorbed. 

Of  the  general  causes,  nutritional  disturhances  and  trophic  influ^ 


DISEASES  OF  BONES  1071 

ences  are  the  most  importaut.  In  old  age  the  entire  skeleton  becomes 
more  or  less  OvSteoporotic,  a  condition  which  predisposes  to  fracture 
of  certain  bones  (such  as  the  neck  of  the  femur)  from  slight  trauma 
and  the  development  of  lordosis.  Atrophy  of  bone  is  especially  marked 
in  the  alveolar  processes,  which  is  responsible  for  the  falling  of  the 
teeth  and  so-called  senile  shortening  of  the  lower  half  of  the  face. 
Senile  atrophy  at  times  makes  its  appearance  in  the  cranium  of  old 
persons,  the  loss  of  substance  being  either  superficial  or  extending 
through  the  entire  bone.  A  similar  change,  occurring  in  young  joer- 
sons  in  connection  with  prolonged  wasting  diseases,  is  designated  as 
marantic  atrophy. 

The  term  neurotic  atrophy  is  applied  to  disappearance  of  bone  struc- 
ture occurring  in  connection  with  lesions  of  the  central  or  peripheral 
nervous  system.  In  growing  bones  this  process  is  attended  with  arrest 
of  development,  and,  in  the  fully  developed,  takes  on  the  form  of  an 
osteoporosis,  at  times  supplemented  by  osteomalacia.  In  paralytic 
cases,  disuse  is  a  causative  factor  in  the  atrophy,  so  that  the  neurotic 
element  alone  is  responsible  for  the  condition  only  in  lesions  which  per- 
mit of  motion,  such  as  tahes  dorsaJis,  syringomyelia,  etc. 

Neurotic  atrophy  of  bones  usually  is  manifested  by  the  occurrence 
of  painless  spontaneous  fractures,  the  repair  of  which  is  attended  with 
excessive  callus  formation,  due  to  the  continual  irritation  of  the  pain- 
less fragments. 

According  to  Baum,^'  fractures  incidental  to  tabes  are  not  due  to 
trophic  disturbances,  but  to  lowering  of  muscle  tone  and  deep  anes- 
thesia, all  of  which  abolish  reflex  muscular  activities  which  normally 
protect  the  bone  against  trauma.  Therefore,  spontaneous  fractures 
occur  only  in  tabetics,  in  whom  the  bones  become  friable  as  the  result 
of  prolonged  disuse. 

Acute  atrophy  of  bone  following  injury  and  inflammatory  processes 
is  also  ascribed  to  trophic  disturbances  by  Sudeck,"  who  seems  to 
have  proved  this  causative  relationship  by  means  of  the  X-ray.  The 
rapidity  of  the  process  cannot  be  explained  on  the  ground  of  disuse, 
and  is  far  more  likely  to  be  due  to  reflex  influences  in  a  manner 
similar  to  that  which  happens  in  arthrogenous  muscular  atrophj^ 
After  the  bone  heals  it  reassumes  its  normal  consistence.  In  cases  of 
articular  tuberculosis  a  doubt  may  arise  as  to  whether  the  diffuse, 
light  bone  shadows  shown  in  the  radiogram  are  due  to  tuberculous  foci, 
or  to  areas  of  acute  atrophy.     The  rapid  extension  of  the  latter, 


1072     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


in  all  the  bones  contiguous  to  the  joint,  should  soon  make  the  differen- 
tial diagnosis. 

Idiopathic  osteopsathyrosis  is  a  rare  form  of  atrophy  of  bone,  the 
cause  of  which  is  unknown.  It  occurs  mostly  in  children  and  is  at- 
tended with  frequent  spontaneous  fractures:  Sudeck"  reports  the 
case  of  a  girl  (twelve  years  of  age)  who,  since  her  second  year  of  life, 
was  afiflicted  with  forty-one  fractures.  M.  B.  Schmidt*  suggests  that 
the  condition  may  be  a  delayed,  mild  form  of  congenital  osteogenesis 
imperfecta  or  an  early  form  of  osteornalacia.  The  latter  cause  was 
established  in  a  case  observed  by  Axhausen.''  M.  B.  Schmidt®  regards 
the  process  as  a  malaciatic  form  of  rachitis,  a  view  which  coincides 
with  that  of  Axhausen. 

Suppurative,  tuberculous,  and 
luetic  osteitis  are  attended  with  i»/?aMi- 
matory  atrophy  of  hone  in  the  course 
of  rarefying  osteitis. 

Hypertrophy  of  Bone.  —  Hyper- 
trophic processes  in  bone  are  fre- 
quently the  result  of  inflammatory 
processes  which,  in  bone  sj-philis, 
lead  to  hyperostosis;  in  periosteal 
tumors  and  in  ulcers  contiguous  to 
the  bone,  to  osteophj'tes ;  in  sup- 
purative osteom3'elitis,  to  the  forma- 
tion of  the  involucrum ;  and  in 
fractures,  to  callus  formation.  Sup- 
purative osteomyelitis  and  tubercu- 
lous bone  and  joint  lesions  in  young 

persons  are  at  times  attended  with  increase  in  the  length  of  growing 
bones. 

A  distinctive  clinical  picture  of  the  process  is  presented  by  two 
forms,  leontiasis  ossea  and  acromegalia. 

Leontiasis  Ossea. —  Leontiasis  ossea  (Yirchow^°)  is  insidious  in 
onset,  begins  early  in  life,  and  gradual!}',  in  the  course  of  several 
decades,  leads  to  a  symmetrical  thickening  of  the  various  hones  of  the 
face  and  skull,  though  usually  it  is  manifested  primarily  in  the  upper 
jaw.  Gradually  the  entire  cranium  is  converted  into  a  heavy,  bony 
mass,  which  robs  the  face  of  all  human  expression. 

The  symptoms  attending  the  affliction  are  not  directly  connected 
with  the  hypertrophic  bone  changes,  which  are  painless  but  secondary 


Fig.  519. —  Leontiasis  Ossea. 


DISEASES  OF  BONES 


1073 


to  them.  When  the  sclerotic  calvarium  reaches  a  thickness  of  from  4 
to  5  cm.,  the  brain  exhibits  evidences  of  pressure,  which  is  expressed 
by  headache,  convulsions,  paralyses,  and  mental  disturbances  of  vary- 
ing magnitude.  The  thickening  of  the  facial  bones  obstructs  and 
displaces  the  nares ;  and  the  eyeballs  are  caused  to  protrude  from  their 
cavities,  so  that  the  drag  on  the  optic  nerves  results  in  blindness.  Pres- 
sure o  n  t  h  e  cranial 
nerves  abolishes  their 
function,  and,  in  the 
instance  of  the  trifacial, 
causes  neuralgia. 

The  causation  of  the 
disease  is  not  known.  In 
a  certain  number  of 
cases,  the  process  is  pre- 
ceded b}'  purulent  infec- 
tion of  the  lacrimal  sac 
and  erysipelas,  though 
their  causative  relation- 
ship is  difficult  to  under- 
stand. Connection 
between  osteitis  fibrosa 
and  di>fusr  osfroDiata 
has  n.ot  been  established. 
Treatment  is  of  no  avail. 
Acromegalia. —  Acro- 
megalia, first  described 
by  P.  Marie"  (1886), 
is  attended  with  hyper- 
trophy of  the  bones 
(which  occurs  as  the  result  of  periosteal  activity),  especially  at  their 
articular  ends  and,  to  a  certain  extent,  involves  the  bones  of  the  face 
and  skull.  However,  the  disease  is  also  accompanied  by  enlargements 
of  soft  parts,  especially  the  nose,  the  ears,  the  lips  and  the  tongue,  and 
at  times  the  penis  and  clitoris. 

The  disease  begins  in  youth  or  in  middle  life  and  is  ascribed  to 
certain  changes  in  the  hypophysis  cerebri  (tumors,  hypertrophy,  cysts, 
sclerosis) .  Its  progress  is  attended  with  paresthesia  and  slight  pain  in 
the  limbs ;  by  the  loss  of  tactile  sense  in  the  hands  and  feet,  and  by  the 


Fig.  520. —  Acromegalia. 
Great  enlargement  of  face  with  heavy  features; 
great  increase   in   sizes  of  hands   with  thickening 
of  the  fingers   (Johnson). 


1074    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

loss  of  sexual  function.  The  bones  of  the  hands  and  feet  gradually 
thicken,  especially  at  their  articular  ends,  so  that  these  extremities 
take  on  the  form  of  paws,  while  at  the  same  time  the  forearms  and 
legs  also  increase  markedly  in  size.  The  joints  undergo  changes 
similar  to  those  in  arthritis  deformans  (Dietrich^^).  The  changes  in 
the  face  become  more  and  more  manifest ;  the  lower  jaw  increases  in 
size ;  and  the  lips,  the  nose,  the  e3'elids,  the  ears,  the  tongue,  and  the 
cheeks  become  enormously  enlarged.  As  time  goes  on,  the  vertebral 
column  becomes  kyphotic,  and  the  bones  of  the  trunk  enlarge.  Ulti- 
mately, a  cachexia  develops  and  the  heart  and  large  vessels  undergo 
degeneration.  While  it  is  true  that  giants  are  likely  to  develop  acro- 
megalia, Arnold^^  states  that  the  disease  is  not  attended  with  increase 
in  the  length  of  the  bones.  Extended  study  of  acromegalia  has  been 
made  by  Gushing^*  (see  bibliography). 

Acromegalia  should  not  be  confused  with  leontiasis  ossea,  since  the 
latter  is  not  attended  with  changes  in  the  fingers  and  toes.  In  ar- 
thritis deformans  the  pathological  process  is  in  the  joints,  in  acromeg- 
alia the  thickening  is  restricted  to  the  articular  ends  of  the  bones 
(Schuchardt^). 

On  the  other  hand,  periosteal  thickening,  similar  to  that  occurring 
in  acromegalia,  develops  at  the  terminal  joints  of  the  fingers  and  toes, 
and  in  the  epiphyseal  areas  of  the  long  bones,  as  the  result  of  cardiac 
and  pulmonary  diseases  in  children  (Bamberger^'').  However,  P. 
Marie^^  regards  this  condition  as  a  distinct  clinical  entit}'  and  gives  it 
the  name  of  oste earth ropatkie  hijpertophiante  pneumique. 

Rachitis,  or  Rickets. —  Rachitis  is  a  term  applied  to  a  general  dis- 
ease of  the  ovsseus  system  occurring  in  children.  The  affliction  is 
widely  known  as  rickets,  though  the  fact  that  it  is  attended  with  curva- 
ture of  the  vertebral  column  led  Marchand^"  to  support  the  use  of  the 
term  rachitis;  on  the  other  hand,  it  was  first  described  by  Glisson" 
(1650)  who  accurately  described  it  under  the  name  of  rickets.  As 
Glisson  was  an  Englishman,  the  disease  was  for  a  long  time  known 
as  the  English  disease,  though  it  was  also,  because  of  the  marked  en- 
largement of  the  joints  with  which  it  is  attended,  called  double  joint 
disease. 

Rachitis  consists  of  a  disturbance  of  the  process  concerned  in  the 
growth  of  bones.  This  is  manifested  by  an  overproduction  of  osteoid 
tissue  devoid  of  lime;  by  defective  calcification  of  new  bone  and  in- 
creased absorption  of  fully  formed  bone  tissue.  These  phenomena  are 
characterized  by  thickening  of  the  epiphyseal  areas  and  mxdtiple  dC' 


DISEASES  OF  BONES 


1075 


formation  of  tubular  bones,  the  result  of  their  consistence,  which 
causes  them  to  bend.  The  lime  content  of  the  affected  bone  is  more 
than  50  per  cent  below  the  normal. 

Osteoid  tissue  is  developed  in  the  form  of  a  vascular  spongy,  soft, 
grayish  mass  on  the  surface  of  the  hone  and  in  its  medullary  substance, 
especially  on  the  metaphyseal  side  of  the  epiphyseal  cartilage.     The 

periosteal  deposit  may  be  "peeled  off" 
from  the  bone,  together  with  the  thickened 
periosteum.  The  myelogenous  deposit,  in 
severe  cases,  occupies  the  entire  meta- 
phj'sis.  The  pathological  proliferation  of 
the  periosteum  and  of  the  endosteum  (a 
thin  membrane  lining  the  bone  and  ex- 
tending between  the  bony  trabeculae)  is, 
according  to  Ziegler,^^  the  initial  step  in 
the  formation  of  osteoid  tissue.  This  is 
followed  by  an  interruption  of  endochon- 
dral ossification,  at  the  site  of  which  the 
process  reaches  its  maximum  of  intensity. 
Fig.    521.— Coronal    Section   The  epiphyseal  cartilages  are  obtrusively 

THROUGH  THE  LowER  END  OF  enlarged  and  exhibit  considerable  increase 
THE  Femur  of  a  Child  Two    .  _,         ,  ..  „ 

AND  A  Half  Years  of  Age  in  cellular  columns.  The  sharp  line  of 
Suffering  with  Eickets  demarcation  between  the  epiphvseal  car- 
(after  Kaufmann).  ^      -u      •     •     n     "^         i  ^i, 

a,  Lower  epiphysis,  normal  t^^^ge  and  the  metaphysis  IS  lost  and  the 
cartilage;  b,  mottled,  bluish  femur  is  flecked  by  irregular  medullary 
red,  swollen,  soft  zone  of  pro- 
liferating cartilage ;  c,  zone  in 
which  the  vessels  and  medul- 
lary spaces  with  osteoid  tissue 
have  penetrated  the  soft  car- 
tilage;    d,     osteoid     tissue;     e, 

dilated    medullarv    cavity    with    •       ,     i  n    j      -.i  »  •  , 

but    little    spongy    boiie;     /,  1^  Studded  With  areas  of  irregular  processes 

thinned  compact  bone  covered  and  Outgrowths,  some  of  which  become 
by  a  laver  of  osteoid  tissue.  ,    t      i>         •  •  7       t         ,. 

separated,    forming   islands   of   cartilage 

within  the  osteoid  tissue,  mingled  with  remnants  of  bony  trabeculae 
and  calcified  cartilage. 

At  the  same  time,  lacunar  absorption  of  fully  developed  bone  tissue 
is  increased,  which,  in  the  tubular  bones,  is  characterized  by  atrophy 
of  the  spongiosa ;  the  haversian  canals  are  enlarged  and  a  distinct 
osteoporosis  is  produced,  while  in  the  flat  bones  certain  areas  dis- 
appear entirely,  to  be  replaced  by  osteoid  tissue.     In  some  instances, 


spaces  and  insular  areas  of  osteoid  tissue, 
while  the  delicate  white  streaks  indicative 
of  primary  calcification  disappear.  In 
this  way,  the  widened  epiphyseal  cartilage 


1076     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


the  process  of  decalcification  of  the  hone  (halisteresis)  resembles  osteo- 
malacia (v.  Recklinghausen^^). 

Rachitic  bone  ma}'  remain  in  a  state  of  defective  calcification  for  a 
long  time.  The  osteoid  tissue  may  be  entirely  devoid  of  calcium  salts, 
or  may  present  certain  restricted  areas  of  calcification.  When  the 
disease  terminates,  the  osteoid  tissue  becomes  calcified  and  the  medul- 
lary canal  is  filled  with  dense,  sclerotic  hone  tissue,  by  means  of  which 
the  coincident  deformities  of  magni- 
tude become  permanent  and  the  lesser 
ones  are  obliterated  by  the  growth  of 
the  bone. 

The  underlying  cause  of  the  grave 
changes  attendant  upon  rachitis  is, 
despite  innumerable  investigations,  still 
a  matter  of  douht.  The  defective  calci- 
fication of  the  newly  formed  bone  is 
ascribed  by  Heubner-°  and  by  Zweifel-^ 
to  faulty  nourishment;  Kassowitz^-  re- 
gards chronic  inflammatory  processes 
as  causative  factors ;  though  neither  of 
these  explanations  withstands  anah^sis. 
Rontgenographs  of  bones,  the  blood 
vessels  of  which  have  been  injected 
with  mercury,  show  these  much  en- 
larged, especially  in  the  metaphysis 
(Delkeskamp-^).  This  suggests  the 
fascinating  possibility  that  certain  un- 
known infections  substances  are  car- 
ried to  the  bone  and  find  residence  in 
the  areas  of  greatest  physiological 
activity  (periosteum  and  epiphyseal 
cartilages),  a  conception  supported  by 

the  work  of  Morpurgo,^*  who  cultured  diplococci  derived  from  rachitic 
rats,  and  by  introducing  these  into  young  rats,  produced  rachitis,  and 
in  adult  rats  provoked  osteomalacia.  The  bacterial  findings  in  epi- 
phj^seal  cartilages  following  infectious  diseases  (Koch,^^  Feher^^) 
and  the  presence  of  necrotic  cartilage  cells  under  similar  conditions 
(Ribbert^^)  argue  for  the  rationale  of  a  bacterial  or  toxic  cause  for 
the  disease.     Stoltzner-^  makes  functional  insufficiency  of  the  supra- 


FiG.  522. —  Genu  Valgum  Adoles- 

CENTIUJI. 


DISEASES  OF  BOXES  1077 

reiwl  capsule  and  its  attendant  arterial  hyperemia  in  the  bone  re- 
sponsible for  rachitis.  Klose^^  observed  rachitic  bone  changes  in 
young  animals  after  removal  of  the  thymus.  An  effort  has  been  made 
to  prove  the  disease  congenital.  It  may  be  stated  with  certainty  that 
the  disease  develops  in  hadJy  nourished  children  who  do  not  get  into 
the  open  air  and  who  have  intestinal  catarrh,  although  the  disease 
occurs  at  times  in  those  fed  from  the  breast. 

Rachitis  begins  usually  in  the  second  gear,  and  diminishes  in  fre- 
quency up  to  the  sixth  year  of  life.  Late  eases  are  probably  exacer- 
bations of  an  earlier,  latent  process.  The  influence  of  heredity  is 
doubtful,  though  its  absence  in  cases  is  certain.  A  peculiar  flexibility 
and  softness  of  the  bones  develops  at  times  at  puhertg,  a  condition 
which  leads  to  habitual  scoliosis,  genu  valgum,  varum  adolescentium, 
coxa  vera,  etc.  It  is  generally  regarded  as  a  late  form  of  rachitis  and 
differs  from  that  of  childhood  with  respect  to  its  location,  being  re- 
stricted to  the  tubular  bones,  the  metaphyses  of  which  are  deficient  in 
lime  content  (Fig.  522). 

The  severest  and  most  obstinate  forms  of  the  disease  are  found 
mostly  in  the  poor  residents  of  cities,  among  whom  ninety  per  cent  of 
the  cases  occur. 

Rachitis  is  an  insidious  disease  and  is  not,  at  first,  readily  diagnosti- 
cated. Experienced  pediatricians  at  times  recognize  the  prodromata, 
which  consist  of  frequent  sweating,  restlessness,  tenderaess  of  the 
bones,  anemia,  and  muscular  weakness. 

The  disease  follows  a  chronic  course,  though  at  times  its  early  stages 
are  attended  with  periods  of  fulminating  progress.  Not  infrequently' 
the  condition  remains  stationary  for  varying  periods  of  time,  to  relapse 
into  additional  progression,  the  latter  being  especially  liable  to  occur 
during  the  winter  months. 

The  hone  manifestations  afford  a  manifold  variety  of  deformities, 
and  at  times  evidence  of  involvement  of  the  entire  skeleton  is  pre- 
sented. In  the  severe  forms  of  the  affliction,  the  child  fails  to  grow 
{rachitic  du'arf)^  thickening  of  the  hones  at  the  zones  of  growth 
appears  in  various  portions  of  the  skeleton,  the  weight  of  the  body  and 
the  tug  of  the  muscles  bends  the  tubular  bones  or  causes  green  stick 
fractures,  while  the  flat  bones  undergo  distinct  atrophic  changes.  In 
milder  cases,  growth  is  barely  delayed,  deformities  are  moderate  in 
degree  and  are  often  limited  to  a  single  area  (such  as  genu  valgum), 
and  the  thickening  of  the  zones  of  ossification  is  slight. 

The  fontanelles  remain   open  until  the  third  or  fourth  year;    the 


I 


1078     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


head  is  large  and  square,  hydrocephalus  is  not  uncommon,  and  the 
parietal  and  frontal  eminences  are  thickened  by  osteoid  deposits. 
The  posterior  cranium  is 
soft  and  compressible 
(craniotahes) .  The  upper 
jaw  shows  deepening  of  the 
palatine  arch  and  is  nar- 
rowed at  its  anterior 
aspect;  the  chin  is  flat. 
Dentition  is  considerably 
delayed  and  is  atypical  in 
sequence. 

The  rihs,  at  the  junction 
of  the  costal  cartilages,  pre- 
sent peculiar  knot-like 
nodes  of  thickening 
(rachitic  rosary).  The  sides 
of  the  thorax  are  drawn 
inward  by  the  action  of  the 
diaphragm  and  the  arc  of 
the  ribs  is  widened.  "When 
the  sternum  is  pushed  for- 
ward the  thorax  takes  on 
the  form  known  as  chicken 
breast  (pectus  carinatum). 
The  curves  of  the  clavicle 
are  exaggerated. 

The  vertehral  column 
shows  a  bow  shaped  kyphos 
in  its  lower  segments,  espe- 
cially in  children  who  are 
carried  very  much;  how- 
ever angulation  is  uncom- 
mon. 

The  pelvis  is  very  likely 
to  be  deformed,  its  errors 
consisting   of   either   sym- 


FlG.    523. —  KiCKETS. 

The  ohanges  are  most  pronounced  in  the 
legs,  -which  are  considerably  shortened.  The 
thighs  are  rotated  outward  because  of  the  dis- 
tortion of  the  neck  of  the  femur.  The  shaft 
of  each  femur  is  bent  forward  and  outward. 
The  tibige  at  the  position  of  the  upper  meta- 
physes  are  bent  inward,  producing  genua  valga. 
The  deformities  at  the  lower  metaphyses,^  re- 
sulting from  a  bending  forward,  are  less  pro- 
nounced. Other  changes  associated  with 
rickets,  such  as  double  flat  foot,  some  thicken- 
ing of  the  lower  epiphyses  of  the  radius  and 
ulna,  Avidening  of  the  costal  arch,  and  the 
rickety  rosary,  are  also  present. 


DISEASES  OF  BONES  1079 

metrical  or  irregular  contractions,  which  deformities  have  an  im- 
portant bearing-  in  childbirth. 

The  hoitcs  of  the  extremities  are  most  often  affected.  The  ends  of 
the  long  bones,  which  are  not  thickly  covered  by  soft  parts,  exhibit 
clearly  defined  areas  of  thickening  (especially  those  near  the  wrist 
and  ankle  joints)  ;  the  diaphyses  are  bent,  those  of  the  thigh  and  leg 
are  bowed  forward  and  outward.  The  bowing  maj"  involve  the  entire 
diaphysis  or  may  occur  near  its  ends.  The  characteristic  bowing  and 
flattening  of  the  shinbone  is  called  saher  tibia.  Acute  angulation  of 
the  meta-  and  diaphyseal  regions  are  due  to  infractions.  Bending  in 
the  region  of  a  joint  produces  malformations,  such  as  genu  valgum, 
flat  foot,  and  deformity  of  the  neck  of  the  femur.  The  bones  of  the 
upper  extremities  also  undergo  deformation,  but  this  happens  only  in 
children  Avho  crawl. 

The  sclerosis  which  terminates  the  disease  usually  begins  a  few 
months  after  the  onset  of  the  affliction,  though  completion  of  the  heal- 
ing process  extends  over  j'ears.  Recovery  is  heralded  by  diminution 
in  the  size  of  the  epiphj'seal  thickening,  by  closure  of  the  fontanelles, 
and  by  resumption  of  growth. 

The  deformities  are  rarely  permanent  to  their  full  extent,  but  recede 
in  proportion  to  the  rapidity  of  the  child's  growth,  and  by  the  time 
adolescence  is  reached  disappear  entirely'.  Usually  two  to  four  years 
are  required  for  the  correction.  In  cases  of  dwarfism  some  correction 
takes  place,  but  this  is  not  complete.  In  seventy-five  per  cent  of  the 
cases,  normal  growth  eliminates  the  deformity  by  the  sixth  or  seventh 
year  of  life.  Malformations  persisting  after  this  length  of  time 
usually  leave  some  permanent,  localized  deformation,  such  as  genu 
valgum. 

The  X-ray  (Fig.  524)  reveals  the  bowing  of  the  tubular  bones  and, 
in  severe  cases,  shows  a  broad,  irregularly  fibrillated  epiphyseal  car- 
tilage, a  thin  corticalis,  and  faint  areas  of  ossification.  When  the 
process  heals  the  epiphj-seal  cartilages  reassume  their  normal  size, 
slender  parallel  strips  of  ossification  appear  in  the  metaphj'ses,  and  the 
corticalis  begins  to  thicken,  especially  on  the  concave  side. 

The  skeletal  manifestations  of  rachitis  are  attended  with  constitu- 
tional symptoms  of  varying  severity;  these  consist  of  moderate  degrees 
of  muscular  weakness  and  atrophy,  anemia,  emaciation,  digestive  dis- 
turbances (meteorism,  diarrhea,  and  obstipation).  The  narrowing  of 
the  thorax  predisposes  to  bronchitis.  Swelling  of  the  lymph  nodes, 
sweating,  eczema,  and  various  functional  neurosesi  are  not  uncommon. 


1080    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 


The  danger,  in  the  severe  forms  of  rachitis,  lies  in  general  lack  of 
resistance  which  renders  the  child  particularly  susceptible  to  inflam- 
matory lesions  of  the  air  passages  and  the  gastro-intestinal  canal-,  and 
especially  to  tuberculosis  and  syphilis.  For  this  reason  many  rachitic 
children  die  of  intercur- 
rent diseases.  Of  itself^ 
rachitis  possesses  an  in- 
herent tendency  toward  re- 
covery, the  latter,  however, 
too  often  is  marred  by  some 
permanent  deformation ; 
this  is  of  especial  import- 
ance in  the  bearing  the 
rachitic  pelvis  has  on  child- 
birth. 

The  diagnosis  is,  as  a 
rule,  not  difficult.  In  doubt- 
ful cases,  the  X-ray  is  of 
great  assistance. 

The  treatment  of  rachitis 
relates  primarily  to  inter- 
nal medicine.  In  this  re 
gard  it  is  proper  to  say 
that  the  most  important 
measure  of  relief  encom- 
passes attention  to  general 
hygiene  and  nourishment. 
The  administration  o  f 
pkospTiorus  would  seem  to 
be  of  therapeutic  value. 

Surgical  efforts  at  relief 
consist  of  the  care  of  frac- 
tures and  the  correction  of 
deformities.    For  the  latter 
purpose,    forcihle    correc- 
tion, either  at  one  sitting  or  frequently  repeated,  and  osteoclasis  (manual 
or  instrumental  fracture),  and  osteotomy  (linear  or  cuneiform)  are 
the  means  generally  employed.     These  measures  should  not  be  used 
until  after  the  sixth  year  of  life,  unless  the  deformity  is  very  marked 


Fig.      524. —  Eontgenogram      of     Eachitic 
Lower  Limb.     (Harlem  Hospital  case.) 


DISEASES  OF  BONES 


1081 


mi 


r^?: 


1^: 


m'ni 


■:\ 


or  unless  sclerosis  is  already  present.  When  the  bone  is  ossified, 
osteotomy  or  osteoclasis  are  the  methods  of  choice.  In  recent  cases, 
however,  surgical  efforts  at  relief  are  contraindicated  on  the  ground 
that  subsequent  immobilization  in  gypsum  is  followed  by  increased 
atrophy,  and  also  because  most  of  the  deformities  are  spontaneously 
corrected.  For  the  same  reason,  the  use  of  ortho- 
pedic apparatus  should  be  avoided.  As  lordosis 
and  flat  foot  are  likely  to  be  permanent,  they  form 
the  exceptions  to  this  rule. 

As  long  as  the  bones  are  soft,  the  child  should 
not  be  permitted  to  walk,  nor  should  it  be  carried 
about  in  the  sitting  posture.  After  sclero.sis 
begins  frequent  motion  in  the  open  air  should  be 
encouraged. 

Scorbutus.  Barbrow's  Disease. —  Barbrow  's,  or 
Holler's,  disease,  also  known  as  osteotahes  in- 
fantum or  infant's  scorbutus,  is  regarded  by  some 
as  a  hemorrhagic  variation  of  rachitis,  and  by 
others  as  a  peculiar  form  of  scorbutus.  Its  cause 
and  behavior  is  not  understood. 

The  disease  begins  with  severe  headache,  which 
is  soon  followed  by  subperiosteal  bleeding  appear- 
ing at  the  lower  end  of  the  femur,  the  upper  tibia 
and,  at  times,  involving  the  humerus  and  bones  of 
the  trunk.  Retrobulbar  bleeding  may  cause 
The  sectioned  femur  exophthalmos.  The  gunis  bleed  and  subcutaneous 
el'^aLl'Va'S^dy  hemorrhages  and  hematuria  occur.  Gradually 
effusion.  New  bone  awewimheralds  the  development  of  the  hemorrhagic 
ben^eSir^^he*''  pe^r^  diathesis.  Absorption  of  the  bones  causes  them  to 
osteum.  The  diaphysis  become  porous  SO  that  very  slight  trauma  pro- 
rha'gic  ^infiltration™"^'  duces  fractures,  infractions  and  separation  of 
epiphyses,  all  of  which  are  attended  with  excessive 
hemorrhagic  infiltration.  Hemorrhagic  areas  often  appear  in  the 
atrophic  bone  marrow. 

The  disease  attacks  children  who  are  improperly  fed  between  the 
sixth  and  twelfth  month  of  life.  It  develops  rapidly  and  ends  fatallj^ 
in  a  few  weeks.  Prompt  administration  of  human  or  properly 
prepared  cow's  milk  is  followed  by  recovery. 


Fig.  52.5. —  Infantile 
Scurvy. 


1082     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

Its  surgical  interest  pertains  to  the  treatment  of  accidental  frac- 
tures and  the  fact  that  it  must  be  taken  into  account  in  connection 
with  diagnosticating  inflammatory  separation  of  epiphyses  and  hotie 
tumors.  The  presence  of  bleeding  from  mucous  membranes  and  the 
occurrence  of  hemorrhages  in  various  portions  of  the  body  should 
render  identification  of  the  disease  easy.  The  X-ray  shows  the  peri- 
osteum lifted  from  the  bone  and  atrophy  of  the  spongiosa  at  the 
metaphyses  (v.  Starck^°). 

Osteomalacia. —  Osteomalacia  is  very  similar  to  rachitis;  it  occurs 
in  adults,  especially  in  women,  in  whom  it  is  attended  with  exacerba- 
tions during  pregnancy  and  lactation  (MacCuUum^^).  It  affects  the 
general  osseous  system  and  differs  from  rachitis  in  attacking  normal, 
fully  developed  bone.  Its  pathological  characteristics  consist  of 
diminution  of  lime  and  the  dominant  development  of  osteoid  tissue. 

Osteomalacia  is  endemic  in  certain  regions,  especially  southern 
Germany,  Italy,  and  Switzerland.  Bossi^-  and  Stoltzner^^  consider 
the  hyperemia  or  vasomotor  disturbances,  consequent  to  adrenal  insuf- 
ficiency, of  etiological  importance.  Erdheim^^  found  lesions  of  vari- 
ous sorts  in  the  parathyroid  glands  and  calls  attention  to  the  parallel- 
ism between  this  condition  and  the  escape  of  calcium  in  parathyroid 
insufficiency. 

The  anatomical  changes  are  not  definitely  understood.  It  is  difficult 
to  decide  whether  the  decalcified  zones  found  on  the  surface  of  the 
trabeculae  of  the  spongiosa  and  within  the  Haversian  canals  are  due 
to  decalcification  {halistcresis  of  v.  Recklinghausen^'')  or  to  the  forma- 
tion of  partially  developed  osteoid  tissue  (Axhausen^*).  M.  B. 
Schmidt^^  is  reluctant  to  set  aside  the  theory  of  halisteresis,  on  the 
ground  that  the  metabolic  changes  coincident  to  rapidly  progressing 
osteomalacia  are  attended  with  the  excessive  elimination  of  lime 
derived  from  the  osseous  system.  According  to  Axhausen^*,  the  lime 
content  of  bone  is  being  given  up  and  replaced  constantly  under 
normal  conditions ;  this  balance  is  seriously  disturbed  in  osteomalacia, 
the  replacement  heing  insufficient,  so  thai  newly  formed  hone  is 
calcified  very  late  or  not  at  all. 

As  a  result  of  these  conditions  the  bones  are  fragile,  and  after  a 
time  become  so  soft  that  weight  bearing  or  the  tug  of  the  muscles 
causes  them  to  bend.  In  some  cases  the  spongy  portion  of  the  bone 
may  be  deformed  by  pressure  with  the  hands.  In  extreme  forms  of 
the  disease,  the  bone  consists  only  of  its  investing  periosteum  which, 
in  the  long  bones,  represents  a  thin  tube  filled  with  degenerated  medul- 


DISEASES  OF  BONES  1083 

lary  substance.  The  medulla  is  markedly  hyperemie,  and  at  first 
contains  extravasated  blood  or  remnants  of  blood  pigment ;  later  it 
becomes  gelatinous  and  undergoes  cystic  degeneration.  New  hone 
occurs  in  restricted  areas  and,  in  the  event  of  fracture,  may  be  depos- 
ited in  excess,  but  this  consists  of  osteoid  tissue  devoid  of  calcium 
salts. 

The  disease  progresses  very  slowly  and  at  times  becomes  transiently' 
stationary'.  Occasionally',  restricted  areas  of  bone  undergo  sclerotic 
changes.  However,  taken  as  a  whole,  the  process  goes  relentlessly 
onward  until  finally  death  ensues. 

The  puerperal  form  of  osteomalacia,  which  may  occur  early  in  preg- 
nancy or  may  not  develop  until  the  postpartum  period,  begins  with 
severe  rheumatic  pains  in  the  lower  portion  of  the  trunk.  The  pri- 
mary bone  lesions  (usually  in  the  pelvis)  develop  gradually'  and  are 
heralded  by  restricted  motility  of  the  hip  joint,  which  is  manifested 
by  a  peculiar  waddling  gait  and  distinct  7'eduction  in  the  length  of 
the  hod)j.  The  neck  of  the  femur  becomes  more  horizontal,  the  tro- 
chanter is  elevated  and  the  acetabulum  and  sacrum  sink  into  the 
pelvic  cavity,  causing  the  latter  to  take  on  the  form  of  a  clover  leaf. 
The  process  is  often  restricted  to  the  bone  primarily  involved  and,  in 
cases  of  moderate  degree,  healing  by  sclerosis  may  occur,  though 
repeated  pregnancies  are  likely  to  be  attended  with  relapse  and 
extension  of  the  disease.  When  the  vertehrce  and  the  bones  of  the 
thorax  become  softened,  the  trunk  collapses  so  that  the  thoracic  wall 
and  the  vertebral  column  undergo  varying"  degrees  of  deformation. 
As  the  disease  progresses,  the  bones  of  the  extremities  are  involved 
and  become  painful  and  tender.  lu  these  situations,  the  deformities 
are  especially  marked,  and  after  a  time  the  bones  become  so  soft  that 
they  are  easily  bent  or  bowed  b}'  the  hands.  Usually  the  bones  of  the 
face  and  cranium  are  not  perceptibly  affected. 

The  patients  are  usually  bedridden  for  years  and  finally  die  as  the 
result  of  exhaustion  or  from  complicating  diseases  of  the  lung,  the 
occurrence  of  which  is  favored  b}^  the  narrowing  of  the  thorax. 

Osteomalacia,  other  than  the  puerperal  form,  is  likely  to  follow  a 
very  stormy  course.  It  usually'  begins  in  the  spine  or  is  ushered  in 
with  repeated  spontaneous  fractures. 

The  diagnosis  of  the  disease  is  possible  only  in  clearly  defined  cases; 
in  the  early  stages  the  X-ray  may  reveal  its  presence. 

The  treatment  should  be  directed  toward  favoring  sclerosing  of  the 
bone.     Most  authors  consider  the  prolonged  administration  of  phos- 


I 


1084    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

phorus  and  cod  liver  oil  useful  in  this  connection.  Attention  to  diet 
and  the  employment  of  apparatus  with  the  view  of  correcting 
deformation  are  advisable. 

During  pregnancy,  the  question  of  emptying  the  uterus  should  be 
given  serious  consideration.  The  measure  has  been  followed  by  arrest 
of  the  disease.  Operative  sterilization  of  afflicted  women  has  also  been 
followed  by  healing  of  the  process. 


^^' 


Fig.  526. —  Bone  Cysts  in  Humerus. 


Paget's  Disease. —  Paget's^^  disease,  also  known  as  osteitis  deformans 
and  designated  as  osteitis  fibrosa  or  metaplastic  osteomalacia  by  v. 
Recklinghausen,^"  resembles  osteomalacia  verj^  closely.  It  is  observed 
in  adults  of  advanced  years,  though  it  may  occur  in  the  second  decen- 
nium  of  life  and  usually  attacks  the  long  tuhular  bones,  the  vault  of 
the  cranium,  the  clavicle,  the  bones  of  the  pelvis  and  spine,  the  ribs, 


DISEASES  OF  BONES  1085 

and  other  bones.  The  disease  begins  with  mild  disturbances  and  is 
later  attended  with  severe  pain  and  gradual  deformation  and  thicken- 
ing of  the  affected  bones.  Spontaneous  fractures  are  not  uncommon. 
As  the  disease  progresses,  the  vertebral  column  collapses  and  locomo- 
tion is  difficult  or  impossible.  Death  is  due  to  pulmonary  infection. 
In  a  certain  number  of  cases  sarcoma  develops  at  one  or  more  of  the 
diseased  areas  of  bone. 

'  The  investigations  of  v.  Recklinghausen  and  Stilling^'-*  leave  the 
causation  of  the  disease  much  in  the  dark.  They  describe  the  process 
as  consisting  of  hone  atrophy  (decalcification  and  lacunar  absorption), 
together  with  massive  formation  of  osteoid  tissue  and  conversion  of 
the  medullary  suhsfance  into  fibrous  tissue  (fibrillary  marrow).  The 
diseased  bone  is  often  the  seat  of  cysts  and  giant  cell  sarcomata.  In 
man}'  cases  the  disease  is  attended  with  increased  elimination  of  lime 
salts  in  the  urine.  On  the  other  hand,  Da  Costa^^  and  his  co-workers 
seem  to  have  shown  that  there  is  a  retention  of  calcium,  magnesium, 
and  phosphorus,  with  excessive  excretion  of  sulphur,  and  they  state 
that  there  have  been  analyses  which  show  that,  in  spite  of  their  soft- 
ness, the  bones  are  especially  rich  in  calcium. 

When  the  clinical  manifestations  of  the  process  are  restricted  to  a 
single  hone,  its  differentiation  from  giant  cell  sarcoma  (which  may  be 
single  or  multiple  or  may  become  cystic),  and  from  hone  cysts  occur- 
ring in  the  metaphyses  of  the  long  bones  (especially  the  femur  and 
humerus)  of  young  people  follow^ing  trauma,  is  attended  with  consid- 
erable difficulty.  This  is  especialh'  true  because  the  latter  often  take 
on  the  form  of  mono-  or  multilocular  cj'sts  surrounded  by  fibro- 
cartilaginous zones  of  thickening  and  are  not  recognized  until  sponta- 
neous fracture  occurs.  A  certain  number  of  these  cases  belong  to  the 
class  of  osteitis  fi-hrosa,  but  should  not  be  considered  so  unless  other 
bones  present  evidence  of  similar  changes,  such  as  the  presence  of 
fibrilla,  bone  marrow,  osteoclasts  and  giant  cells,  old  bone  trabeculae 
containing  remnants  of  calcium,  and  young  trabeculae  consisting  of 
osteoid  tissue  devoid  of  calcium  (v.  Recklinghausen^'').  Another 
class  of  cases  belongs  to  that  of  tumor  formation  (cystic  chondroma, 
chondrofibroma,  sarcoma).  As  sarcoma  is  likely  to  develop  within  an 
area  of  osteitis  fibrosa,  a  decision  in  this  connection  is  a  difficult  matter. 
When  arriving  at  a  conclusion,  osteitis  serosa,  rarefying  hone  processes, 
cystic  degeneration  of  callus  tissue,  the  changes  in  Basedow's  disease, 
and  parasitic  cysts  must  be  taken  into  account  (Tietze^^). 

Osteitis  fibrosa  ma}'  be  mistaken  for  inflammator}-  thickening  of  bone 


1086     DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

occurring  in  connection  with  chronic,  purulent  and  luetic  osteitis, 
though  the  use  of  the  X-ray  should  clear  up  this  aspect  of  the  problem. 
Treatment  is  unsatisfactory.  The  emplojTnent  of  apparatus  is  of 
no  value.  The  fact  that  operative  attack  in  the  form  of  osteotomy  with 
the  view  of  correcting  deformities  is  not  followed  by  union  of  the  sec- 
tioned bone  renders  the  measure  valueless  (Schuchardt^).     When  the 


Fig.  527. —  Paget  's  Disease  or  Osteitis  Deformans. 

Thickened  skull  and  cross  section  of  femur.      Marrow  cavity  filled  with  osteoid 
tissue  (From  MacCallum's  "  Text  Book  of  Pathology  ")• 


disease  is  restricted  to  a  single  bone  in  an  extremity,  amputation  may 
be  considered  (Schmieden^").  Bone  cysts  are  at  times  obliterated 
during  the  repair  of  a  spontaneous  fracture,  and,  in  some  instances, 
curettement  is  followed  by  healing  (Schmieden^^). 

Mother-of- Pearl  Workers'  Bone  Disease. —  Juvenile  mother-of-pearl 
workers  are  at  times  suddenly  attacked  with  painful,  elastic  swelling 


DISEASES  OF  BONES  1087 

of  the  bones.  After  the  swelling  subsides,  the  bone  presents  circum- 
scribed areas  of  thickening-.  The  lesion  usually  develops  in  the  long 
tubular  bones  in  the  region  of  the  metapJiyses,  and  may  extend  to  the 
contiguous  epiphyses  or  diaphyses.  The  short  and  flat  bones  are 
occasionally  involved.  The  various  bones  are  attacked  at  intervals, 
while  the  primary  focus  becomes  additionally  thickened.  The  process 
is  never  attended  with  severe  symptoms  or  necrosis.  It  disappears 
when  the  causative  occupation  is  given  up. 

The  lesion  is  most  frequently  located  in  a  metaphysis.  Gussen- 
bauer,'"*  basing  his  conclusion  on  experimental  observations,  states  that 
the  mother-of-pearl  dust  gains  access  to  the  blood  through  the  lungs 
and  is  deposited  in  the  bone,  where  it  gives  rise  to  irritation  and 
inflammation.  Broca  and  Tridon^^  found  the  lesion  to  consist  of  a 
rarefying  osteitis. 

The  condition  may  be  confused  with  the  subacute  forms  of  suppu- 
rating osteomj^elitis. 

The  treatment  consists  of  change  of  occupation. 


BIBLIOGRAPHY 

1.  Kaufman.     See  Sehuehardt  No.  3. 

2.  HORSLEY.     See  Sehuehardt  No.  3. 

3.  SCHUCHARDT.     Deutseh.  Chir.,  1890,  with  lit. 

4.  V.  EiSELSBERG.     Deutseh.  Chir.,  IflOl. 

5.  BiRCHER.     Deutseh.  Zeitsehr.  f.  Chir.  xeviii,  1909. 

6.  Baum.     Quoted  by  Sehuehardt  No.  3. 

7.  SuDECK.     Fortsehr.  a.  d.  Gebiet.  d.  Roentgenstr.  Bd.  5,  1902;    also  the 

same  Bd.  3,  1900. 

8.  M.  B.  Schmidt.     Verb.  d.  path.  GeseL,  1909. 

9.  AxHAUSEN.     Deutseh.  Zeitsehr.  f.  Chir.  Bd.  92,  1908. 
LO.  ViRCHOW.     See  Sehuehardt  No.  3. 

U.  P.  Marie.     Rev.  de  Med.,  1886,  vi,  and  1890,  x. 

12.  Dietrich.     See  Sehuehardt  No.  3. 

L3.  Arnold.     See  Sehuehardt  No.  3. 

14.  CusiiiNG.     Jr.  A.  M.  A.,  1909;    with  Crowe.  Quart.  Jr.  Exper.  Phys., 

1910,  xxxvii.  No.  60. 

15.  Bamberger.     See  P.  Marie  No.  11. 

16.  Marchand.     Verh.  d.  path.  GeseL,  1909. 

17.  Glisson.     See  Marehand  No.  16. 
L8.  ZiEGLER.     Zentrbl.  f.  path.,  1901. 

19.  V.   Recklinghausen.     Untei-sueh   u.    Rachitis   and   Osteomalzie,   Jena, 

1910,  with  lit. 

20.  Hbubner.     Lehrbuch  d.  kinderkr.,  Leipzig. 

21.  Zweifel.     At,  Prophyl.  und  Therapie  d.  Raehitis,  Leipzig,  1900. 

22.  Kassowitz.     Deutseh.  med.  Woeh.,  1913. 

23.  Delkescamp.     Fortsehr.  a.  d.  Gebiet.  d.  Rontgenstr.  Bd.  10,  1906. 


1088    DISEASES  OTHER  THAN  INFECTIONS  AND  TUMORS 

24.  MoRPURGO.    Verb.  d.  path.  Gesel.,  1907. 

25.  Koch.     Verb.  d.  path.  Gesel.,  1909. 

26.  Feher.     Virchow's  Arch.  Bd.  213,  1913. 

27.  RiBBERT.     Deu'.sch.  med.  Woch.,  1913. 

28.  Stoltzner.     Verh.  d.  path.  Gesel.,  1909. 

29.  Klose.     Neue  Deutsch.  Chir.  Bd.  3,  1912. 

30.  V.  Starck.     Munch.  lued.  Woch.,  1907. 

31.  MacCullum.     Text  Book  of  Path.,  Phila.,  1916. 

32.  Bossi.     Zentrbl.  f.  Gyn.,  1907. 

33.  Erdheim.     Sitz.  d.  k.  Akad.  d.  Wiss,  Wien.  Math.  Natur.  kl.,  1909,  cxvi, 

Abth.  iix. 

34.  AxHAUSEN.     Zentrbl.  f.  Path.,  1908. 

35.  M.  B.  Schmidt.     Ergeb.  d.  Alls:.  Path,  von  Lubarscb  u.  Ostertag,  1900. 

36.  Paget.     Med.  Chir.  Trans.,  1877,  Ix ;    also  1882,  Ixv. 

37.  DaCosta  and  others.     Pub.  of  Jeff.  Med.  Coll.,  Phila.,  1916,  vi. 

38.  TiETZE.     Ergeb.  d.  Chir.  u.  Orthoped.  Bd.  2,  1911. 

39.  Schmieden.     Deutsch.  Zeitschr.  f.  Chir.,  1903,  Bd.  70. 

40.  Gussenbauer.     Arch.  f.  klin.  Chir.  Bd.  18,  1875. 

41.  Broca  and  Tridon.    Rev.  de  Chir.,  1903. 


PART  VI 

TUMORS 


CHAPTER  I 

DEFINITION     AND     CLASSIFICATION     OF     TUMOES 

The  terms  tumor,  genuine  or  autonomous  growth,  new  formation, 
neoplasm,  and  hlastoma  are  not  properl}-  applicable  to  cellular  pro- 
liferation occurring  in  a  certain  tissue,  but  may  be  used  when  new 
formations  possess  certain  characteristics  of  which  the  following  may 
be  regarded  as  determining : 

1.  The  development  of  a  tumor  is  independent  of  the  organism,  except 
that  nourisliment  is  derived  from  it. 

2.  The  structure  of  the  growth  varies  from  that  of  its  normal  surround- 
ings, and  this  derivation  must  be  atypical  from  its  beginning. 

3.  Its  growth  does  not  attain  typical  limits,  i.  e.,  it  exhibits  a  tendency 
toward  progressive  growth  despite  the  fact  that  this  may  be  transiently 
arrested  or  maj^  even  recede  for  a  time.  Many  benign  tumors  cease  to  grow 
after  a  certain  degree  of  development  is  reached,  though  spontaneous  involu- 
tion is  exceedingly  rare.  Necrosis  of  tumor  growth  is  not  a  genuine 
involution. 

4.  The  causes  of  tumor  growth  are  unknown. 

If  these  be  the  chief  characteristics  of  genuine  tumors,  they  may  be 
regarded  as  presenting  conditions  of  development  quite  distinct  from 
all  hypertrophies,  hyperplasias,  inflammatory  swellings,  and  infectious 
granulomata  (occurring  in  connection  with  tuberculosis,  actinomyco- 
sis, glanders,  lepra,  lues,  rhinoscleroma) .  In  these  processes  tissue 
proliferation  does  not  deviate  from  physiological  construction ;  it  is 
usually  limited  to  connective  tissue  which,  in  the  process  of  prolifera- 
tion, takes  on  an  emhryonic  character  but,  owing  to  the  presence  of  a 
causative  irritation,  does  not  go  on  to  the  formation  of  fully  developed 
scar  tissue.  The  causative  factor  consists  of  a  definite  mechanical  or 
bacterial  irritation,  and  when  this  is  removed  the  tissue  is  converted 
into  that  of  adult  type.  There  are,  however,  tumors  which  it  is  diffi- 
cult to  differentiate  from  hyperplastic  growths,  especially  those  of  an 
inflammatory  nature,  as  their  cellular  elements  do  not  markedly  differ 
from  those  of  normal  growth  (Virchow*). 

Cysts  (sacs  filled  with  fluid  or  caseous  masses)  should  be  classified 
with  true  tumors  in  two  instances  only :   (1)  When  th^^y  are  developed 

1091 


1092  TUMORS 

from  solid  tumors  (degenerative  cysts,  cyst  adenomata)  ;  (2)  when 
the  tissues  comprising  their  walls  proliferate  and  take  on  the  character 
of  a  new  growth  (epithelial,  dermoid,  teratoid  cysts). 

It  is  desirable  that  the  classification  of  tumors  be  based  on  their 
etiology.  As  we  do  not  know  anything  of  this,  they  are  classified, 
very  much  as  are  animals  and  plants,  on  the  basis  of  their  most  domi- 
nant characteristics  (MacCallum-).  An  effort  to  base  a  classification 
of  tumors  on  clinical  observation  is  equally  unsatisfactory.  Therefore 
(since  the  work  of  Virchow^)  an  effort  has  been  made  to  formulate  a 
working  basis  upon  their  histological  and  histogenic  relations  which, 
according  to  Ribbert,^  leads  to  their  arrangement  in  six  groups  as 
follows : 

I.  Tumors  of  the  connective  tissue  class : 

A.  Fibroma,  composed  of  connective  tissue. 

B.  Lipoma,  composed  of  fatty  tissue. 

C.  Chondroma,  composed  of  cartilage. 

D.  Osteoma,  composed  of  bone. 

E.  Angioma,  composed  of  blood  vessels. 

F.  Sarcoma,  composed  of  unripe  connective  tissue  rich  in 

cellular    elements,    with    its    subdivisions    com- 
posed of : 

a.  cells  of  any  of  the  connective  tissues. 

b.  cells  resembling  lymphoid  cells. 

c.  mucoid  tissue  (myxoma,  myxosarcoma). 

d.  pigmented  cells  (melanoma,  chromatophoroma). 

II.  Tumors  developing  from  muscle  tissue : 

A.  Rhabdomyoma,  composed  of  striated  muscle. 

B.  Leiomyoma,  composed  of  smooth  muscle. 

III.  Tumors  composed  of  nervous  tissue : 

A.  Neuroma,  developing  from  nerves  and  ganglion  cells. 

B.  Glioma,  developing  from  glia  cells. 

IV.  Tumors  developing  from  epithelium: 

A.  Fibro-epithelial  tumors. 

B.  Carcinoma,  with  its  subdivisions  depending  upon  the 

origin  of  the  epithelium. 

V.  Tumors  composed  of  endothelium. 

VI.  Mixed  tumors. 

According  to  Virchow  V  original  conception,  tumors  may  be  divided 
into  histoid  tumors,  the  structure  of  which  closely  resembles  that  of 


DEFINITION  AND  CLASSIFICATION  1093 

normal  tissue  (e.  g.,  fibroma,  lipoma,  osteoma)  ;  organoid  tumors,  which 
resemble  in  structure  the  various  viscera,  being  composed  of  an  inter- 
stitial tissue  and  parenchyma;  systematoid  or  teratoid  tumors,  consist- 
ing of  a  complicated  organic  structure  resembling  that  of  the  body  or 
a  part  of  it. 

BIBLIOGRAPHY 

1.  ViRCHOw.     Die  krank.  Gesehwiilste,  Berlin,  1863. 

2.  MacCallum.     Text  Book  of  Path.,  Phila.,  1916. 

3.  RiBBERT.     Gesehwiilstlehre,     Bonn,    1904;     also     Beitr.    z.    Ensteh.    d. 

Gesehwiilste,  Bonn,  1906. 


CHAPTER  II 
ETIOLOGY  OF  TUMOES 

The  origin  and  proliferation  of  tumor  cells  is  controlled  by  laws  the 
nature  of  which  is  unknown.  A  number  of  conditions  favoring  their 
development  seem  to  have  been  established  which,  as  the  real  cause  of 
tumor  genesis  is  unknown,  possess  considerable  importance. 

Heredity  undoubtedly  plays  a  part  in  the  causation  of  tumors. 
This  consists  in  part  of  the  displacement  or  separation  of  germinal 
tissue  from  its  normal  connections  during  the  development  of  the 
embryo,  and  in  part  in  the  persistence  of  emhrijonic  tissue  which  nor- 
mally undergoes  involution,  the  latter  being  in  a  sense  a  local  tissue 
malformation  (CohnheimM.  In  this  way  displaced  or  residual  em- 
bryonic cells  may  proliferate  typically  or  atypically  and  be  present  in 
utero,  develop  during  childhood  or  (less  often)  evince  evidence  of 
their  growth  later  in  life.  Thus  epidermoids  and  dermoids  arise  from 
displaced  cells  of  the  ectoderm ;  enterocysts  from  those  of  the  germinal 
mucosa;  tumors  from  displaced  adrenal,  thyroid,  and  mammary  rests, 
from  branchial  clefts,  the  urachus  and  vitelline  ducts;  true  mixed 
tumors  and  teratomata  from  residual  emhryonic  tissue.  To  these  may 
be  added  the  heterologous  tumors  (of  Virchow-),  W'hich  undoubtedly 
develop  from  displaced  germinal  tissue;  these  differ  from  homologous 
tumors  in  that  they  develop  in  tissues  or  organs  to  which  they  bear  no 
histological  resemblance  (lipoma  in  the  pia  and  the  drain,  myoma  in 
the  kidney,  chondroma  in  a  vital  organ)  and  tumors  consisting  of 
congenital  malformations  such  as  pigmented  skin  moles.  It  is  un- 
doubted that  a  number  of  tumor.s,  such  as  angiomas,  lipomas,  chon- 
dromas, myomas  and  sarcomas  owe  their  origin  to  an  inherited  predis- 
position, especially  when  they  develop  in  conjunction  with  malforma- 
tions of  various  kinds. 

That  inflammatory  processes  and  trauma  often  precede  tumor  form- 
ation is  well  known  to  every  clinician.  However,  the  manner  in  which 
these  presumably  causative  factors  act  is  not  clear. 

Tissue  changes  engendered  by  persistent  irritation,  the  result  of 

1094 


ETIOLOGY  OF  TUMORS  1095 

mechanical  influences  or  chronic  inflammatary  processes,  seem  to  pre- 
sent conditions  favorable  to  tumor  formation.  Favorable  conditions 
m  this  connection  obtain  in  the  chronic  eczema  of  paraffin  and  coal  tar 
workers;  in  chronic  balanitis  due  to  jjhimosis;  in  the  chronic  inflam- 
matory conditions  of  the  scrotal  skin,  seen  in  chimney  sweeps;  in  the 
chronic  dermatitis  due  to  frequent  exposure  to  the  X-ray,  which  is 
often  followed  by  carcinoma.  Carcinoma  is  very  likely  to  develop  in 
chronic  ulcers,  such  as  ulcers  of  the  leg  and  stomach,  and  frequently 
follows  ulcer  of  the  tongue  and  cheek  (from  injury  due  to  carious 
teeth),  ulcQrated  skin  tuberculosis  and  syphilis,  persistent  fisiulce 
(bone  necrosis  and  fistula  in  ano),  and  scars,  especially  those  following 
prolonged  ulceration.  Occasionall}',  hyperplastic  new  growths,  such 
as  leukoplakia,  hyperkeratosis,  papillary  warts  and  mucous  polj'pi 
develop  into  carciuomata,  sarcomata  or  melanomata. 

A  single  trauma  as  a  causative  factor  in  connection  with  tumor 
formation  obtains  only  in  connection  with  epithelial  cysts  of  the  palm 
of  the  hand,  in  which  portions  of  the  skin  are  carried  into  the  deeper 
structures  by  penetrating  agents,  such  as  occur  in  stab,  incised  or 
gunshot  wounds. 

In  all  other  cases  the  causal  relationship  between  trauma  and  the 
development  of  a  tumor  has  not  been  established.  It  is  possible, 
when  sarcoma  develops  at  the  seat  of  a  fracture,  a  carcinoma  of  the 
stomach  after  a  contusion  of  the  abdominal  wall,  etc.,  that  the  tumor 
was  already  present  at  the  time  of  the  trauma  but  gave  rise  to  no 
symptoms,  attention  being  drawn  to  it  by  the  injury  (Cohnheim^) . 

On  the  other  hand,  it  is  certain  that  trauma  and  chronic  inflamma- 
tory processes,  stimulating  as  they  do  the  regenerative  activity  of  the 
tissues,  exercise  a  distinct  influence  upon  the  growth  of  existing 
tumors.     This  is  an  important  point  in  accident  insurance. 

The  rapid  dissemination  of  malignant  disease  following  incomplete 
removal  or  the  application  of  caustic  acids  is  a  matter  of  common 
observation. 

Borst's^  statistical  review  states  that  a  causal  relationship  between 
trauma  and  tumor  formation  varies  from  2.5  to  44.7  per  cent,  a  wide 
divergence  which  suggests  that  its  existence  may  be  regarded  as 
doubtful. 

Heredity  or  congenital  predisposition  is  more  or  less  manifest  as  an 
etiological  factor  in  certain  classes  of  tumor  formation.  It  seems  to 
obtain  in  connection  with  nevi,  angiomata,  multiple  fibromata  of  the 
skin  and  nerves,  lipomata,  enchondromata,  and  exostoses  when  these 


1096  TUMORS 

appear  both  early  and  late  in  life.  In  some  instances,  tumors  appear 
not  alone  in  the  same  family  hut  also  in  the  same  portion  of  the  body. 
The  writer  has  seen  a  pigmented  mole  situated  at  the  side  of  the  neck 
of  a  father  repeated  in  the  same  situation  in  each  of  five  children  and 
in  one  (the  only)  grandchild.  Liicke  and  Zahn*  state  that  the  hered- 
itary influence  in  carcinoma  is  10.5  per  cent. 

At  this  writing  it  is  feasible  to  arrange  the  various  conceptions  con- 
cerning the  development  of  tumors  in  two  groups.  To  the  first  belong 
the  hypotheses  of  Cohnheim^  and  of  Ribhert,^  according  to  which 
tumor  proliferation  develops  from  embryonic  cells  and  those  of  extra- 
uterine life  that  are  separated  from  their  organic  connection  and  dis- 
placed. The  second  group  combines  the  hypotheses  according  to  which 
tumors  develop  from  normally  placed  cells  of  the  body  which,  as  the 
result  of  unknown  influences,  through  irritation  of  various  kinds 
(Yirchow-),  perhaps  also  from  parasites,  acquire  the  capacity  of 
unrestrained  proliferation. 

According  to  Cohnheim,'^  all  genuine  tumors  are  traceable  to 
superfluous,  displaced  or  ahnormally  persistent  embryonic  tissue  ele- 
ments, which  are  caused  to  proliferate  by  various  accidental  factors. 
Borst*  summarizes  these  factors  as  increased  nutrition,  decrease  of 
resistance  to  growth,  physiological  increase  or  decrease  of  local  or 
general  growth. 

This  hypothesis  is  supported  by  tumors  that  undoubtedly  develop 
from  displaced  or  non-involuted  embryonic  groups  of  cells,  such  as 
dermoids  and  teratomas,  the  tumors  of  accessory  organs  and  displaced 
adrenal  rests,  cysts  arising  from  the  branchial  clefts,  the  urachus,  the 
vitelli7ie  and  thyroglossal  ducts. 

However,  generalization  of  Cohnheim's  theory  is  not  feasible. 
First,  it  is  not  possible  to  accept  an  embryonic  causation  for  tumors 
that  habitually  appear  late  in  life;  again,  while  attempts  at  trans- 
plantation of  embryonic  tissue  into  animals  of  the  same  species  has 
been  attended  with  additional  growth  and  involution,  proliferation  has 
always  been  restricted  to  a  brief  period  of  time  and  has  never  resulted 
in  genuine  tumor  formation  (Schmieden,**  Wilms,'^  Woglum,®  Levin, 
Lambert,  Hanes,  and  MacCallum,^  Borst,^  Apolant^°), 

According  to  Ribbert,^  genuine  tumors  develop  from  germinal 
TISSUE,  which  is  either  displaced  during  embryonic  growth  or  is 

SEPARATED,  BY  TRAUMATIC  OR  INFLAMMATORY  INFLUENCES,  FROM  ITS 
physiological  CONNECTIONS  DURING  LATER  LIFE  AND  THUS  BECOMES  AN 
INDEPENDENT    ENTITY    CAPABLE    OF    GROWTH.      Ribbcrt     COUsidcrs    this 


ETIOLOGY  OF  TUMORS  1097 

independence  on  the  part  of  the  displaced  germinal  tissue  explanatory 
of  its  unrestricted,  atypical  growth,  on  the  ground  that  cells  which 
bear  a  normal  relationship  to  the  organism  as  a  whole  are  subject  to 
physiological  limitations  of  growth  and  development,  while  excessive 
proliferation  of  cells  occurs  in  response  to  the  hyperemia  and  irritation 
attendant  upon  inflammatory  processes. 

RibbertV'  assumption  regarding  postembryonic  dissociation  of 
groups  of  cells  from  their  organic  connection  is  supported,  as  far  as 
trauma  is  concerned,  by  the  development  of  epithelial  cj'sts  in  the 
palm  of  the  hand,  which  are  sequential  to  penetration  of  the  deeper 
tissues  by  portions  of  epidermis.  The  isolation  of  cellular  elements 
can  be  demonstrated  in  connection  wdth  chronic  inflammatory  processes 
occurring  in  glandular  structures  in  which  cells  are  separated  from 
their  normal  environment  and  encapsulated  by  proliferating  connec- 
tive tissue.  The  structure  of  the  isolated  germinal  tissue  determines 
the  character  of  the  tumor,  thus,  a  fibroma  develops  from  connective 
tissue,  a  lipoma  from  fatty  tissue,  and  carcinoma  from  epithelium. 
When  the  germinal  connective  tissue  matrix  remains  embryonic  in 
type,  sarcoma  develops. 

Ribbert's'*  hypothesis,  like  that  of  Cohnheim,^  attempts  to  place 
tumor  genesis  upon  a  single,  definite  basis.  It,  however,  also  assumes 
the  existence  of  unknown  influences  w^hich  cause  the  displaced  cells  to 
develop  new  growth,  as  these  do  not  of  themselves  possess  this  capacity. 
It  is  certain  that  innumerable  attempts  at  transplantation  of  tissue  of 
various  kinds  have  never  been  followed  b}'  tumor  formation.  It  is 
also  true  that  many  diseases  are  attended  with  cellular  and  tissue 
embolism  (bone  marrow,  giant  cells,  fat,  liver  and  placental  cells,  and 
chorionic  villi)  without  the  occurrence  of  tumorous  proliferation  of 
the  isolated  displaced  cellular  elements  (Borst^).  The  work  of 
Ehrlich^^  throws  some  light  upon  the  nature  of  the  influences  which 
cause  the  cells  to  proliferate.  According  to  this  prolific  scientist,  the 
organism  possesses  certain  protective  substances  which  hinder  ab- 
normal proliferation  (athreptic  immunity),  and  this  immunity  may  be 
artificially  increased  by  implantation  of  tumor  material  or  embryonic 
tissue  derived  from  another  organism  (Schone^-).  The  elements 
necessary  to  the  proliferation  of  tumor  germs  do  not  become  available 
until  this  immunity  is  decreased.  Normally,  the  cells  of  the  body 
possess  sufficient  avidity  for  nutritive  substances  so  that  the  tumor 
germs  are  not  nourished,  but  when  this  aviditj^  is  at  a  low  ebb  tumor 
proliferation  begins. 


1098  TUMORS 

Hauser^^  holds  that  tumors  may  develop  from  normally  situated 
cells.  This  conception  presupposes  that  the  cells  undergo  certain  bio- 
logical changes  which  cause  them  to  proliferate.  It  has  been  assumed 
that  normal  and  normally  situated  cells  when  subjected  to  irritation 
are  stimulated  into  increased  proliferation,  and  that  they  develop 
reproductive  energy  simultaneously  with  lessening  of  their  functional 
activities  (Benecke,"  Hauser/^  0.  Israel/^  Lubarsch^*'),  or  that  they 
assume  toxic  properties  (Marchand^'^)  which  are  destructive  to  their 
surroundings,  making  infiltrating  proliferation  possible. 

Thiersch^^  suggests  that  with  respect  to  carcinoma,  lessening  of  the 
growth  of  the  connective  tissue  in  localized  areas  permits  the  domina- 
tion of  epithelial  proliferation,  an  idea  that  v.  Hansemann^"  elabo- 
rated by  attempting  to  define  the  character  of  this  change  in  the  cells, 
which  he  describes  as  anaplasia,  an  alteration  in  the  cell  not  easily 
recognized  by  its  form,  but  consisting  in  changed  histological  char- 
acters which  allow  it  to  proliferate  rather  thayi  to  functionate.  This, 
in  its  more  intense  degree,  is  accompanied  by  change  in  the  form  and 
arrangement  of  the  cells  and  is  associated  with  atypical  or  asymmetri- 
cal mitoses ;  but  the  term  is  descriptive  of  the  changes  which  occur  in 
cells.  Borst,^  recalling  the  infinite  complexity  of  the  processes  of  the 
distribution  of  parental  characters  to  all  the  cells  of  the  developing 
body,  regards  the  change  in  the  cells  which  leads  to  tumor  growth  as 
due  to  some  irregularity  in  the  formation  of  their  ''idioplasm,"  which 
one  sided  development  does  not  necessarily  incapacitate  them  for  an 
ordinary  function  in  the  ranks  of  other  cells,  but  leaves  them  capable 
of  independent  and  atypical  growth.  Schwalbe-°  adheres  to  this  idea 
which  he  expresses  differentl}^,  inasmuch  as  he  speaks  of  congenital 
pathological  abnormality  of  the  cells,  or  cell  malformation  (MacCal- 
lum"^).  In  the  development  of  malignant  growths  the  anaplastic  cells 
alone  proliferate  in  response  to  irritation,  while  normal  cells  are  sim- 
ply concerned  in  hyperplasia  in  its  widest  sense.  It  is  a  fact  that 
many  tumor  cells  closely  resemble  the  simple  structure  of  their  embry- 
onic prototypes;  thus,  large  connective  tissue  cells  devoid  of  intercel- 
lular fibrillae  are  found  in  sarcomas,  and  epithelial  cells  which  do  not 
cornify  and  do  not  secrete  mucus  are  found  in  many  carcinomas  of 
the  skin  and  mucous  membranes.  Ribbert'  regards  the  phenomena  of 
reversion  to  a  primitive  type  as  unnecessary  to  tumor  formation,  but 
considers  it  merely  as  a  factor  which  favors  growth  when  tumors 
develop  from  fully  differentiated  elements. 

The  parasitic  theory,  based  on  the  notion  that  genuine  tumors  are 


I 


ETIOLOGY  OF  TUMORS  1099 

the  outcome  of  infection  with  parasitic  organisms,  does  not  rest  upon 
a  firm  basis.  Innumerable  attempts  have  been  made  to  establish  its 
rationale  in  carcinoma  and  sarcoma.  The  most  obvious  explanation 
of  this  connection  would  seem  to  lie  in  the  existence  of  a  living  organ- 
ism, continually  stirring  the  tissues  to  grow ;  but  in  that  case  it  would 
be  necessary  for  the  parasite  to  associate  itself  indissolubly  with  the 
cell  and  accompany  it  in  all  its  wanderings  and  divisions.  No  such 
parasite  has  been  found  (MacCallum-^).  The  bacteria  found  in 
tumors  have  been  shown  to  be  harmless  saprophytes.  The  hlasto- 
myces,  protozoa,  rhizopoda,  infusoria,  and  sporozoa,  described  as  resi- 
dents of  tumors,  have  been  shown  to  be  altered  tumor  cells  undergoing 
regression,  such  as  vacuole,  keratohyalin  and  colloid  formation ;  or 
cell  inclusions,  consisting  in  part  of  degenerated  leukocytes  or  epithe- 
lium (Borst^).  The  lack  of  similarity  in  the  findings  alone  argues 
strongly  against  their  etiological  significance.  On  the  other  hand, 
Lowenstein-^  found  a  worm  of  the  nemataid  class  (trichodes  crassi- 
cauda  specifica)  in  the  urinary  passages  of  the  rat,  which  he  regards 
as  respouvsible  for  papillary  and  infiltrating  neoplasms.  Fibinger^^ 
seems  to  have  shown  that  certain  tumors  found  in  the  stomach  of  the 
rat  (papilloma  and  carcinoma)  are  caused  by  the  presence  of 
nematoids. 

While  a  number  of  investigators  have  cultivated  various  parasites 
derived  from  fresh  tumors,  Otto  Schmidt-*  is  the  only  one  who,  by 
using  cultures  derived  from  mucor  racemosus,  which  is  regarded  as 
the  intermediary  host  of  cancer  excitants,  succeeded  in  producing 
tumors.  However,  the  w^ork  of  Schmidt  was  not  substantiated  by  that 
of  V.  Wasielewsky  and  Wiilker,^^  who  attempted  to  duplicate  it. 

The  transplantation  of  living  tumor  tissue,  that  is,  the  transplanta- 
tion of  cancer  tissue  into  another  portion  of  the  afflicted  patient  (Hahn, 
V.  Bergmann,  Cornil^^)  and  of  tumor  tissue  derived  from  animals  into 
animals  of  the  same  species  —  dogs,  rats,  mice,  etc.  (Novinsky,  Weber, 
Hanan,  V.  Eiselsberg,  Jensen  and  others-^),  has  been  more  encouraging. 
The  most  valuable  findings  are  those  of  Ehrlich^^,  whose  work  is  also 
important  in  other  directions.  By  repeated  retransplantation  of 
mouse  cancer  tissue  from  mouse  to  mouse,  Ehrlich  was  able  to  increase 
the  virulence  or  the  proliferative  capacity  of  the  tumor  transplant,  so 
that  ultimately  growth  occurred  in  each  instance.  In  some  instances, 
in  the  course  of  the  proceedings  the  transplanted  tissue  changed  its 
character,  as  epithelial  proliferation  was  progressively  dominated  by 
the  more  actively  proliferating  connective  tissue,  so  that  carcinomatous 


1100  TUMORS 

tissue  was  converted  into  sarcomatous  tissue  and  into  genuine  sarcoma. 
As  regards  the  bearing  these  observations  have  on  the  parasitic  theory 
(similar  to  the  so-called  inoculation  recurrences  in  the  scar  tissue 
following  operations  for  removal  of  carcinoma),  they  simply-  show  that 
incapsuiated  well  nourished  tumor  cells  may  develop  in  other  parts 
of  the  body.  Successful  transplantation  means  that  the  implanted 
cells  have  retained  their  energy  to  grow;  not  that  an  infectious  para- 
sitic cause  of  tumor  formation  has  been  inoculated  with  it.  The  result 
of  Keysser's^^  experimental  work  suggests  the  possibility  of  an  infec- 
tious cause  for  tumor  development.  Keysser  used  cell  free  ascitis  fluid 
and  filtered  tumor  extract  derived  from  mice  suffering  from  carcinoma 
of  the  liver,  injecting  them  into  the  organs  of  normal  mice,  with  the 
result  that  the  latter  developed  infiltrating  tumor  growths.  This 
observation  was  substantiated  by  E.  Henke,-^  who  obtained  similar 
results  under  similar  circumstances. 

From  a  clinical  standpoint  the  facts  favoring  the  parasitic  theory 
would  seem  to  be  applicable  onh'  to  carcinoma  (Czemey^°),  as  when 
carcinoma  occurs  in  situations  especiaUy  subjected  to  external  influ- 
ences (the  face,  neck,  hands).  Also,  the  lesion  commonly  develops  in 
situations  frequently  subjected  to  trauma,  which  apparently  provides 
ports  of  entrance  for  infection  (ulcers  of  all  kinds,  fistulfe,  eczema, 
scars  following  wounds  or  ulcers,  fissured  nipples,  erosions  of  the 
uterine  cervix)  ;  or  in  situations  where  there  has  been  a  prolonged 
irritation  (chronic  dermatitis,  hyperkeratosis,  seborrhea,  eczema, 
leukoplakia,  chronic  balanitis  in  phimosis).  This  would  apply  also  to 
the  digestive  tract,  where  cancer  occurs  most  often  in  zones  subjected 
to  irritation  of  a  traumatic  or  inflammatory  character  (edge  of  the 
tongue  from  carious  teeth,  esophagus,  cardia,  pjiorus,  flexures  of  the 
colon  and  rectum).  Lack  of  cleanliness  seems  to  lend  support  to  the 
parasitic  theory,  as  cancer  frequently  appears  on  the  faces  of  poor 
people,  in  the  mouths  of  those  who  neglect  the  teeth,  and  in  the 
breasts  of  women  who  do  not  cleanse  the  nipple.  Additional  evidence 
in  this  connection  is  adduced  from  the  occurrence  of  so-called  contact 
carcinoma  or  cancer  hy  implantation,  in  support  of  which  multiple 
carcinoma  cf  the  gastro-intestinal  canal,  the  development  of  cancer  of 
the  mucosa  of  the  cheek,  in  contact  with  a  cancerous  tongue,  of  the 
upper  and  lower  lip,  the  vulva,  apposed  surfaces  of  peritoneum,  and 
the  almost  simultaneous  occurrence  of  cancer  in  several  members  of 
a  family  are  quoted. 

On  the  other  hand,  the  persistence  of  a  certain  type  of  tissue  in 


ETIOLOGY  OF  TUMORS  1101 

tumors  and  their  metastases,  apparently  transmitted  as  stated,  argues 
strongly  against  the  parasitic  theory  of  transmission.  It  is,  however, 
not  necessary  that  the  cells  of  each  kind  of  tissue  of  the  body  should 
possess  a  certain  definite  affinit}'  for  a  specific  parasite  (Borst^).  The 
explanation  may  well  lie  in  the  conversion  of  a  normal  body  cell  into  a 
tumor  cell  as  the  result  of  unknown,  presumably'  exceedingly  variable 
influences  (Lexer^^). 


BIBLIOGRAPHY 

1.  CoHXHEiM.     Vorlesung.  u.  All.frem.  Path.,  Berlin,  1882. 

2.  ViRCHOW.     Die  krank.  Geschwiilste,  Berlin,  1863. 

3.  BORST.     Die   Lebre   d.    Geschwiilste,    Wiesbaden,    1902,    with   lit.;    also 

WiirzburErer  Abhandl.  Bd.  6;  also  Aschoff's  path.  Anat.  Bd.  i,  1911. 

4.  LiJCKE  and  Zlnx.     Deutsch.  Chir.,  1896. 

5.  RiBBERT.     Gescbwiilstlehre,     Bonn,    1904;     also    Beitr.    z.     Ensteh.    d. 

Gesebwiilste,  Bonn,  1906. 

6.  SrHMiEDEX.     Deutsch.  Zeitscbr.  f.  Chir.  Bd.  70,  1903. 

7.  WiLirs.     Chir.  kong.  Verb.,  1904. 

8.  "WoGLUir.     Crocker  Research  Fund,  New  York,  1913. 

9.  Levix,  Lambert,  Hanes,  and  MacCallum.     Crocker  Research  Fund, 

1912. 

10.  Apolaxt.     Zeitscbr.  f.  Allg.  Pbys.,  1909,  ix,  with  lit. 

11.  Ehrlich.     Zeitscbr.   f.  Artz.   Fortbild.,  1906;   also   Arb.   a.   d.   Inst.   f. 

Exper.  Therap.,  Jena,  1906. 

12.  ScHOXE.     Weicbardt's  Jabresbericbt  d.  Immunitatsforscb  Bd.  ii,  1908; 

also  Beitr.  z.  klin.  Chir.  Bd.  61,  1909. 

13.  Hatjser.     See  Borst  No.  3. 

14.  Bexecke.     See  Borst  Xo.  3. 

15.  0.  Israel.     Berlin  klin.  Wocb.,  1900,  xxxvii. 

16.  Lubarsch.     Wiesbaden,  1899 ;  also  Jabreskurse  f .  iirzt.  Fortbild,  1910. 

17.  Marchaxd.     See  Borst  No.  3. 

18.  Thiersch.     See  Borst  No^  3. 

19.  V.  Haxsemaxx.     Anaplasie,  etc.,  Berlin,  1893-1897. 

20.  Schwalbe.     Verb.  Natur.  Med.  Vers.,  Heidelberg,  1906,  N.  F.  viii. 

21.  MacCallum.     Textbook  of  Path.,  Pbila..  1916. 

22.  Lowexsteix.     Beitr.  z.  klin.  Cbir.  Bd.  76,  1911. 

23.  FiBixGER.     Berlin,  klin.  Wocb.,  1913,  No.  7. 

24.  Otto  Schmidt.     See  No.  25. 

25.  V.  Wasielewsky  and  Wulker.     Miincb.  med.  Wocb..  1912.  with  lit. 

26.  Hahx,  v.  Bkrgmaxx,  and  Corxil.     Quoted  by  Apolant  in  Kolle-Was- 

sermann's  Handb.  d.  patb.  Mikroorg.  2  Aufl.  Bd.  3,  1913,  with  lit. 

27.  NovixsKY,  Weber,  Haxax,  v.  Eiselsberg,  Jexsex,  and  otbers.     Same 

as  No.  26. 

28.  Ketsser.     Zeitsehr.  f.  Chemotherap.  Heft,  ii,  and  xii,  1914;  also  Wiener 

klin.  Wocb.,  1913,  No.  41. 

29.  E.  Hexke.     Deutsch.  med.  Wocb..  1916,  No.  41. 

30.  Czerxet.     Beitr.  z.  kHn.  Chir.  Bd.  25.  1899. 

31.  Lexer.     Allgem.  Chir.  ii,  Stuttgart,  1914. 


CHAPTER  III 
FOEM,   GROWTH,  AND  CLINICAL  SIGNIFICANCE   OF   TUMORS 

Among  the  varied  forms  that  tumors  assume,  the  round  nodular  is 
the  most  common.  As  tumors  develop  their  form  is  influenced  by 
their  anatomical  environment,  so  that  deformation  of  various  kinds 
takes  place.  Tumors  on  the  surface  of  the  skin  and  mucous  mem- 
branes may  be  attached  by  broad  or  narrow  pedicles  and  are  fungoid, 
verrucous,  villous,  papillary  and  cauliflower-like  in  appearance.  Sev- 
eral different  forms  may  be  combined  in  the  same  tumor. 

The  growth  of  a  tumor  either  displaces  or  infiltrates  the  tissues  con- 
tiguous to  it.  The  former  is  called  expansive,  the  latter  infiltration 
growth.  The  increase  in  size  of  a  tumor,  according  to  Ribbert,^  is 
attained  as  the  result  of  proliferation  of  its  own  constituents  and  not, 
as  was  formerly'-  believed,  by  transformation  of  the  invaded  tissue  into 
tumor  cells,  nor  by  proliferation  of  the  latter  into  tumor  masses.  A 
tumor  growing  by  expansion  has  sharply  defined  borders,  is  readily 
separated  from  its  environment,  and  is  usually  surrounded  with  a 
distinct  capside  formed  by  thickening  of  the  surrounding  connective 
tissue,  while  infiltrating  growth  has  more  or  less  indistinct  boundaries 
and  is  intimately  connected  with  the  surrounding  tissues.  A  primarily 
expanding  growth  may  later  become  infiltrating. 

The  nourishment  of  a  tumor  is  furnished  by  blood  vessels  which 
enter  it  from  its  surroundings.  When  a  tumor  grows  slowly  the  blood 
suppl}^  is  sufficient  for  its  nourishment ;  when,  however,  growth  is 
rapid  it  is  insufficient,  and  certain  portions  of  the  proliferated  mass 
undergo  fatty  or  mucoid  degeneration  and  necrosis.  In  pediculated 
tumors  the  circulation  is  at  times  interfered  with,  so  that  ihe  tumor 
mass  and  its  surroundings  become  edematous. 

Regressive  changes  in  infiltrating  tumors  may  be  caused  by  invasion 
of  the  blood  vessels  by  proliferating  tumor  elements,  by  means  of 
which  the'vessels  are  obstructed.  This  is  followed  by  the  formation 
of  cavities  in  the  deeper  portions  of  the  growth,  by  ulceration  of  its 
surface,  and  at  times  by  shrinkage  of  the  entire  mass. 

1102 


FORM,  GROWTH  AND  CLINICAL  SIGNIFICANCE     1103 

The  clinical  significaiice  of  tumors  lies  in  the  damage  they  do  as  the 
outcome  of  their  growth,  together  with  the  harm  resulting  from  their 
character.  Expansive  tumors  do  damage  b}^  the  pressure  they  exert 
upon  more  or  less  important  structures.  For  instance,  pressure  upon 
blood  vessels  causes  disturbances  of  the  circulation,  pressure  upon  the 
spinal  cord  and  nerves  is  attended  with  paralj'^sis,  and,  when  it  is 
exerted  upon  the  brain,  it  is  often  fatal.  On  the  other  hand,  tumors 
situated  upon  the  surface  of  the  body  may  reach  considerable  dimen- 
sions without  causing  serious  disturbances.  Infiltrating  tumors,  how- 
ever, make  serious  pressure  upon  the  tissues  that  they  invade  and  give 
rise  to  atrophy  and  may  destroy  entire  organs  or  erode  the  walls  of 
important  vessels. 

Tumors  are  also  harmful  because  of  their  tendency  to  recur  and 
because  of  the  metastases  and  cachexia  attendant  upon  their  develop- 
ment. 

Recurrence  follows  incomplete  operative  removal  of  a  tumor  more 
frequently  in  connection  with  an  infiltrating  than  with  a  circumscribed 
encapsulated  growth.  Recurrences  obtain  in  situations  where  tumor 
cells  have  been  conveyed  into  the  surrounding  tissues  by  the  lymph- 
atics, conditions  under  which  extension  of  the  growth  is  exceedingly 
rapid.  Return  of  the  growth  at  its  primary  seat,  after  wide  removal, 
occurs  most  often  in  keloid,  which  seems  to  possess  a  peculiar  idiosyn- 
cracy  in  this  connection. 

The  term  metastatic  growth  is  applied  to  the  development  of  a  sec- 
ondary growth  at  a  distance  from  the  site  of  its  primary  appearance. 
When  a  tumor  growth,  in  the  course  of  its  proliferation,  invades 
lymph  or  Mood  vessels,  cells,  groups  of  cells  and  tissue  particles  are 
conveyed  to  more  or  less  remote  portions  of  the  bod}",  these  elements 
causing  the  development  of  metastases.  Extension  of  a  new  growth  to 
contiguous  IjTnph  vessels  gives  rise  to  the  formation  of  secondary 
(IjTnphogenous)  tumors.  When  tumor  cells  enter  blood  vessels  or 
gain  access  to  the  thoracic  duct,  as  is  often  the  case  in  connection 
with  extensive  carcinoma  and  sarcoma,  their  final  disposition  occurs 
in  accord  with  the  laws  of  embolism  {hematogenous  metastases) . 

When  the  veins  of  the  general  circulator])  system  are  invaded  the 
tumor  elements  are  conveyed  to  the  lungs,  the  capillaries  (over  0.6  mm. 
in  diameter)  of  which  permit  their  passage  into  the  left  heart,  whence 
they  enter  the  arterial  system  and  are  deposited  in  vascular  portions  of 
the  body  supplied  with  capillaries  of  narrow  caliber  (liver,  kidney, 
and  less  often  the  bones  and  skin).    Death  is  at  times  caused  by  the 


1104  TUMORS 

lodgment  of  an  embolus  of  this  sort  in  the  pulmonary  artery.  Tumor 
cells  derived  from  the  portal  system  are  primarily  lodged  in  the  liver. 
It  is,  of  course,  not  known  how  many  tumor  cells  are  destroyed  in  the 
lymph'  and  blood  streams,  nor  how  many  are  deposited  in  various  por- 
tions of  the  body  without  proliferating.  There  is  no  doubt  that  many 
degenerated  and  not  a  few  viable  tumor  cells  gain  access  to  the  circu- 
lation. This  is  shown  by  experimental  demonstration  of  the  presence 
of  protective  or  immune  bodies  in  the  blood  and  suggests  that  not  all 
liberated  cells  are  capable  of  producing  metastases. 

Extension  of  tumor  growth  by  means  of  the  lymph  and  blood  streams 
occurs  in  other  ways.  First,  by  continuity  in  which  tumor  prolifera- 
tion extends  within  the  lumen  of  the  walls  of  the  vessels;  e.  g.,  carci- 
noma grows  for  some  distance  in  a  lymph  vessel  to  an  adjacent  node ;  or 
carcinomas  of  the  stomach  and  the  gut  extend  into  the  radicals  of  the 
portal  vein,  and  sarcoma  or  hypernephroma  enters  the  renal  vein  and 
is  carried  into  the  inferior  vena  cava  and  on  into  the  right  heart. 
Second,  by  retrograde  extension,  i.  e.,  wandering  of  the  cells  against 
the  normal  direction  of  the  affected  blood  vessel.  This  occurs  in  in- 
stances of  marked  venous  stasis,  in  which  the  impulse  transmitted  by 
the  right  heart  to  the  tumor  is  stronger  than  the  force  of  the  blood 
stream  (Ribbert^).  The  occlusion  of  a  main  lymphatic  vessel  may 
direct  the  stream  into  another  direction,  so  that  the  cells  are  deposited 
in  other  portions  of  the  body,  though  extension  of  growth  in  the  lym- 
phatics usuall}^  follows  the  course  of  the  adjacent  vessels  and  is  infre- 
quently retrograde. 

In  serous  cavities,  tumor  cells  are  disseminated-  on  the  surfaces  of 
the  investing  membrane  (peritoneum,  pleura,  pericardium)  by  the 
movements  of  the  contained  organs.  During  operative  removal  of  a 
tumor,  trauma  to  the  growth  may  liberate  some  of  its  cells,  which  are 
thus  accidentally  grafted  into  the  wound  and  subsequently  give  rise  to 
the  development  of  implantation  metastases  or  become  responsible  for 
recurrences. 

The  secondary  growth  is  always  of  the  same  structure  as  the  pri- 
mary. 

The  development  of  metastases  is  peculiar  to  infiltrating  tumors; 
expanding  tumors  do  not  gain  access  to  lymph  and  blood  vessels.  On 
this  difference  of  mode  of  extension,  not  on  the  variations  in  the  char- 
acter of  the  tumor  cell,  rests  the  clinical  difference  (though  this  is  not 
always  clearly  defined)  between  benign  and  malignant  growths  (Rib- 
bert^).    Benign  growths  are  usually  restricted  to  localized  areas  and 


FORM,  GROWTH  AND  CLINICAL  SIGNIFICANCE     1105 

are  dangerous  only  when  they  attain  great  size  or  involve  important 
organs;  malignant  tumors  tend  toward  general  dissemination  and  by 
the  activity  of  proliferation  destroy  the  host.  The  more  closely  tumor 
elements  resemble  embryonic  tissue,  the  more  rapid  is  their  prolifera- 
tion and  the  more  certain  their  infiltrating  growth. 

The  pernicious  effects  of  tumors  upon  the  general  organism  appear 
in  the  form  of  a  gradual  diminution  of  the  vital  forces  —  cachexia 
which  is  especially  manifest  in  malignant  growths  in  the  stage  of  the 
metastatic  formation ;  nor  is  this  phenomenon  restricted  to  the  class  of 
tumors  mentioned.  It  also  attends  the  growth  and  development  of 
benign  tumors  when  these  are  of  great  size  (myoma  of  the  uterus,  giant 
fibrolipoma  of  the  skin)  or  are  multiple  (diffuse  lipoma).  Cachexia  is 
due  to  a  number  of  causes.  It  is  consequent,  not  alone  to  disturbances 
of  the  invaded  organs,  to  interference  with  normal  functional  activi- 
ties or  the  proper  nourishment  of  the  body,  to  pain  and  loss  of  sleep, 
but  is  also  the  outcome  of  self  intoxicatian,  which  is  attended  with  fever 
and  is  caused  b}^  the  absorption  of  disintegrated  tumor  masses  (prote- 
olji:ic  ferments)  and  the  products  of  putrefaction  from  ulcerating 
areas  of  new  growths  (Lewin^)  ;  to  which  may  be  added,  that  the  re- 
gressive changes  in  tumor  tissue  are  often  attended  with  menacing 
complications,  such  as  aspiration  pneumonitis  in  carcinoma  of  the 
upper  air  passages  or  peritonitis  consequent  to  perforating  carcinoma 
of  the  stomach. 


BIBLIOGRAPHY 

1.  RiBBERT.     Gesehwiilstlehre,     Bonn,    1904;     also    Beitr.    z.    Ensteh.    d. 

Geschwiilste,  Bonn,  1906. 

2.  Lewin.     Die  Bosartigen  Geschwiilste,  Leipzig,  1909. 


CHAPTER  IV 

THE  DIAGNOSIS  OF  TUMORS  IN  GENERAL 

Differentiation  of  genuine  new  growth  from  hyperplasias,  inflamma- 
tory infiltrates,  infectious  granulomata,  and  cyst  formations,  and  recog- 
nition of  the  character  of  a  tumor  is  based : 

I.  On  the  previous  and  present  history  of  the  case,  which  includes 
consideration  of  the  time  the  lesion  first  makes  its  appearance  and  the 
mode  of  its  growth,  together  with  the  local  and  constitutional  disturb- 
ances it  produces. 

II.  On  the  physical  findings,  (A)  the  local,  (B)  the  general  exami- 
nation, combined  with  (C)  consideration  of  what  varieties  of  tumors 
are  most  frequently  found  in  the  part,  tissue,  or  organ  involved,  and 
(D)  special  diagnostic  methods. 

A.     The  Local  Examination  determines  the  seat  and  the  peculiari- 
ties of  the  tumor  by  means  of  inspection  and  palpation. 

Inspection  determines: 

1.  The  seat  and  the  extent  of  the  tumor  in  relation  to  visible 
anatomical  structures,  i.  e.,  sector  of  body,  bone,  muscle,  ten- 
dons, etc. 

2.  The  form  —  round,  oval,  irregular,  flat,  nodular,  semiglobu- 
lar,  pediculated,  fungiform,  papillary,  or  cauliflower. 

3.  The  size,  compared  to  known  objects,  such  as  a  pea,  a  cherry, 
a  walnut,  a  hen's  q^^,  an  infant's  head ;  or  accurate  measure- 
ments may  be  taken. 

4.  The  surface: 

a.  Covered  with  skin  or  mucous  memhrane,  normal,  per- 
meated by  dilated  blood  vessels,  hyperemia,  pigmented, 
tense,  glistening,  or  transparent. 

b.  Sloughing,  ulcerated,  secreting,  bleeding  readily,  or 
covered  with  crusts. 

c.  Edges  of  the  ulcer  elevated  or  flat,  sharp,  undermined, 
excoriated,  hard  or  soft. 

1106 


THE  DIAGNOSIS  OF  TUMORS  IN  GENERAL        1107 

d.  Floor  of  the  ulcer  flat,  depressed,  crater-like  or  filled 
with  villosities,  necrotic,  uneven,  smooth,  or  fissured. 

e.  Surrounding  tissue  normal,  elevated,  or  invaded  by 
secondary  nodules. 

f.  Margins  sharply  defined  or  indistinct,  circumscribed 
or  diffuse. 

Palpation  determines: 

1.  The  relationship  a  tumor  hears  to  its  coverings,  i.  e.,  may 
the  superimposed  skin  be  raised  in  folds  like  that  of  the  nor- 
mal skin?  is  the  skin  or  mucous  membrane  movable  over  the 
growth  ?  is  the  growth  beneath  the  muscle  ?  The  last  may  be 
determined  by  lifting  the  muscle,  or  by  causing  the  muscle 
to  contract;  for  instance,  by  contracting  the  abdominal 
muscles  or  by  active  elevation  of  the  arm,  so  as  to  cause  the 
deltoid  muscle  to  contract. 

2.  The  form  of  the  surface  of  a  tumor,  i.  e.,  smooth  and  regular, 
nodular,  lobulated  or  irregular. 

3.  The  boundaries  of  a  tumor;  palpation  determines  whether 
these  are  sharply  defined  or  indistinct. 

4.  The  seat  of  a  tumor  from  an  anatomical  standpoint,  that  is, 
its  relationship  to  contiguous  tendons,  muscles,  bones,  and 
organs. 

5.  The  relation  a  tumor  hears  to  its  surraundings  and  underly- 
ing structures.  Does  it  move  with  the  skin  or  with  the  soft 
parts?  is  it  deeply  attached  to  bone,  tendons,  or  fascia?  does 
it  move  with  a  tendon,  a  muscle,  or  with  the  liver  during 
inspiration? 

6.  The  consistency  of  a  tumor,  whether  hard  or  soft.  On\j  the 
experienced  hand  is  able  to  make  fine  distinctions  as  to 
whether  a  growth  consists  of  cartilage,  bone,  or  ihity  tissue, 
or  whether  it  gives  the  "feel"  of  a  hard  or  soft  fibroma. 

a.  Fluctuation:  Hard  as  well  as  soft  tumors  fluctuate, 
depending  upon  whether  the  capsule  containing  fluid 
or  the  'Soft  tumor  mass  is  tensely  or  moderately  dis- 
tended. A  hard  fluctuating  tumor  is  elastic.  The 
capsule  of  soft  tumors  must  be  made  tense  before 
fluctuation  is  elicited.  In  firmly  attached  and  in 
slightly  movable  tumors,  fluctuation  is  elicited  in  the 
same  wav  as  in  abscesses.     The  index  flngers  of  both 


1108  TUMORS 

hands  should  be  placed  opposite  each  other  upon  the 
tumor,  first  at  a  small,  later  at  a  greater,  distance 
apart.  The  fingers  should  be  laid  flat  and  slightl}^  ap- 
posed to  the  tumor  mass.  The  left  index  finger  (inac- 
tive finger)  is  held  still  while  pressure  is  made  with  the 
right  (active  finger),  which  is  then  quickly  withdrawn, 
The  inactive  finger  is  palpably  lifted  by  the  displaced 
fluid. 

If  the  tumor  is  movable,  it  is  grasped  between  the 
index  fingers  and  the  thumbs  of  both  hands.  "When 
fluid  is  present,  pressure  with  the  fingers  of  the  right 
hand  lifts  those  of  the  left.  Pseudofluctuation  is 
elicited  in  soft  tumors  (lipoma,  myxoma). 

b.  Doughy  or  kneadable  consistency  is  imparted  to  the 
palpating  hand  by  dermoid  cysts  and  accumulation  of 
feces.  These  are  often  deformed  by  the  pressure  of 
the  fingers  and  when  released  slowly  reassume  their 
original  conformation. 

c.  Pulsation,  felt  by  the  hand  applied  without  pressure 
is  produced  by  certain  hemangiomas ;  pressure  upon 
the  main  artery  aholishes  it. 

d.  Compressible  tumors  are  made  smaller  by  pressure  and 
reassume  their  original  shape  when  the  pressure  is  re- 
moved  (hemangioma  and  lymphangiomas). 

e.  Thrill,  often  felt  by  the  apposed  hand  in  pulsating 
tumors. 

f.  Parchment  crepitation  is  elicited  from  tumors  covered 
by  a  thin  shell  of  bone. 

B.     The  General  Examinatiox  includes: 

1.  Palpation  of  neighhoring  lymph  nodes,  which  in  cases  of 
malignant  disease  are  enlarged  and  hard. 

2.  Search  for  analagous  new  growth  (multiple  tumors)  and  for 
metastases  of  the  skin,  organs  and  bones. 

3.  Special  examination  of  the  various  organs  and  organic  sys- 
tems. For  instance,  the  urine  is  examined  for  the  presence 
of  albumin,  blood,  and,  in  cases  of  suspected  pancreatic 
growths,  for  sugar;  in  intestinal  lesions,  the  feces  are 
scrutinized  for  blood,  mucous,  etc. ;  in  tumors  of  the  stomach, 
the  gastric  juice  is  examined;  the  functional  activities  of  the 


b 


THE  DIAGNOSIS  OF  TUMORS  IN  GENERAL        1109 

kidneys^  are    tested^  iu    separated    specimens    obtained    by 
catherization  of  the  ureters;  when  tumor  of  the  central  and 
peripheral  nervous  system  is  suspected,   nerve  function  is 
standardized ;  in  cases  of  growths  of  the  blood  forming  or- 
gans, the  relationship  of  the  cellular  elements  of  the  hlood 
to  each  other  is  of  importance. 
4.      Judging  of  the  general  condition  of  the  host,  cardiac  func- 
tion, anemia,  digestion,  physical  and  mental  resistance. 
C.     What  Tumors  or  Tumor-Like  New  Growths  Are  Likely  to 
Occur  in  a  Given  Area  or  Organ?    For  instance,  in  the  j^ahn 
of  the  hand  an  indefinitely  fluctuating  round  tumor,  slightly 
movable  upon  the  deeper  tissues,  but  not  attached  to  the  ten- 
dons, is  discovered.    A  similar  tumor  in  the  region  of  the  eye,  a 
place  where  dermoid  cysts  are  common,  would  be  regarded  as 
such.     In  the  hand,  however,  dermoids  are  never  found,  but 
epithelial  cysts  are  common,  while  the  latter  never  appear  near 
the  eye. 

When  a  tumor  is  manifestly  attached  to  a  nerve  its  round- 
ness and  hardness  and  the  fact  that  it  is  not  attached  to  the 
skin  or  deeper  tissues  would  suggest  a  number  of  possibilities. 
However,  the*  consideration  that  it  is  connected  with  a  nerve 
reduces  speculation  to  those  growths  finding  origin  in  nerves, 
namely,  glioma  and  neuroma. 

The  seat  of  a  tumor  is  especially  significant  in  connection 
with  the  mammarij  gland,  where  many  new  growths  and  tumor- 
like hyperplasias  are  found,  which  do  not  make  their  appear- 
ance in  other  portions  of  the  body.  A  lobulated,  nodular,  soft 
mass  covered  by  soft  skin  and  freely  movable  should  not,  as  is 
the  case  on  the  back,  be  at  once  regarded  a^  a  lipoma.  The  re- 
lationship of  the  tumor  to  the  gland  tissue  must  be  taken  into 
account,  as  a  lipoma  may  be  present  behind  the  gland.  Again, 
at  times  the  entire  gland  is  hypertrophied  or  filled  with  small 
cysts  (matistis  chronica  cystica),  conditions  which  closely  simu- 
late subcutaneous  lipoma.  Indeed,  the  male  breasts  may  be 
the  seat  of  the  same  growths  that  obtain  in  the  female,  aside  from 
the  peculiar  female  character  the  male  breast  at  times  assumes 
{gynccoynastia,  Fig.  528).  In  the  breast,  carcinoma  shows  cer- 
tain peculiarities,  such  as  retraction  of  the  nipple,  which  often 
makes  early  recognition  of  the  process  possible. 

In  the  hones,  myelogenous  sarcoma,  chondroma,  and  osteoma 


1110 


TUMORS 


are  most  often  found  in  the  epiphyses  and  metaphyses,  while 
periosteal  sarcoma  frequently  invades  the  diaphyses.  However, 
a  flat  or  nodular,  not  clearly  defined,  immovable  thickening  of 
bone  covered  by  normal  skin,  must  not  be  dismissed  with  the 
hasty  conclusion  that  sarcoma  is  present.  On  the  contrary,  con- 
ditions of  this  sort  often  attend  chronic  suppurative  and  tuber- 
culous osteomyelitis  and,  above  all,  are  a  part  of  periosteal  syph- 
ilitic granulation  tumors,  especially  in  the  tibial  diaphyses,  so 


Fig.  528. —  Male  with  Gynecomastia. 


that  in  making  the  diagnosis,  evidence  of  infectious  processes 
in  other  portions  of  the  body  must  be  carefully  sought  after. 

Examples  of  this  sort  might  be  greatly  multiplied;  however, 
those  maintained  should  show  that  the  diagnosis  of  tumors 
necessitates  a  knowledge  of  special  pathology,  much  prac- 
tice in  the  interpretation  of  the  available  data  and  a 
considerable  clinical  experience. 

Despite  this,  the  nature  of  a  new  growth  is  not  always 


THE  DIAGNOSIS  OF  TUMORS  IN  GENERAL        1111 

ESTABLISHED  WITH   CERTAINTY,  AND  IN    MOST   CASES   IS   ONLY   RE- 
DUCED TO  A  PROBABILITY. 

D.  Additional  information  is  gained  by  aspiration,  exploratory  in- 
cision, the  X-ray,  and,  in  cases  of  abdominal  tumors,  by  the 
employment  of  Special  Measures. 

1.  Aspiration  is  helpful  when  determination  of  the  consistence 
of  a  mass  presents  difficulties.  Introduction  of  the  needle 
determines  the  presence  and  the  character  of  fluid,  i.  e., 
whether  bloody,  purulent,  mucous,  etc. 

2.  Exploratory  incision  often  reveals  the  nature  of  a  growth  as 
the  result  of  macroscopic  scrutiny  of  a  sectioned  surface,  so 
that  lipoma,  sarcoma,  mammary  fibroma  or  carcinoma  may 
be  differentiated. 

At  times  it  is  necessary  to  excise  a  portion  of  a  growth  for 
the  purpose  of  microscopical  examination.  This  is  especially 
helpful  during  the  early  development  of  a  growth.  A  small 
wedge-like  piece  is  excised  from  the  surface  of  the  tumor  and 
the  wound  sealed  with  the  cautery.  Specimens  from  the 
larnyx  should  be  removed  under  the  guidance  of  the  laryn- 
goscope. 

In  a  number  of  instances,  small  particles  of  tumors  are 
spontaneously  thrown  off   (e.  g.,  tissues  expectorated  from 
the  air  passages,  vomited,  or  passed  in  the  urine  and  feces) 
and  may  then  be  examined. 
3.      The  X-ray  is  useful  in  hard  tumors.     Those  consisting  of 
bone    (osteoma,    osteosarcoma)    or    containing    bone    tissue 
(teratoma)   may  often  be  differentiated  from  inflammatory 
infiltrates  and  hyperostoses.    Tlie  condition  of  the  bone  from 
which  tumors  arise  is  very  variable,  being  either  destroijed 
or  retaining  its  original  conformation.     Exostoses  are  con- 
nected with  the  surface  of  normal  bone  by  broad  or  narrow 
pedicles ;  periosteal  sarcomas,  at  least  at  first,  surround  nor- 
mal bone  which  is  clearly  outlined  against  the  new  growth. 
In  the  medullary  form  of  osteosarcoma  the  bone  is  soon  de- 
stroyed.    Small  central  tumors  may  be  differentiated  from 
inflammatory  foci  when  the  thickened  area  is  surrounded  by 
a  thin  layer  of  corticalis.    As  a  rule,  the  bone  surrounding 
an  inflammatory  lesion  is  much  thickened.     It  is,  at  times, 
possible  to  see  where  a  central  tumor  has  ruptured  through 
the  thickened  corticalis. 


CHAPTER  V 

THE  TREATMENT  OF  TUMORS  IN  GENERAL 

Thorough  and  complete  operative  removal  of  tumors  is  thi 
MOST  certain  therapeutic  measure.  It  is  indicated  in  the  treat] 
ment  of  all  TUMORS,  with  the  exception  of  benign  tumors  which  do" 
not  cause  disturbance  and  where  the  operation  would  be  severe  or  un- 
warranted mutilation  result.  Small  tumors  of  the  skin  may  be  removed 
by  elliptical  incisions  which  permit  of  ready  repair  by  suture.  On  the 
face  it  is  necessary  at  times  to  make  plastic  repair  with  the  view  of 
obviating  deformity. 

Malignant  tumors  should  be  excised  early  in  the  process.  This 
should  include  a  section  of  the  contiguous  normal  tissue,  together  with 
the  adjacent  lymph  nodes,  irrespective  of  whether  the  latter  are  visibly 
involved  or  not.  This  statement  is  not  susceptiUe  to  qualification  in 
any  regard. 

Malignant  tumors  become  inoperable,  first,  because  of  the  extent  of 
the  primary  growth  ;  second,  because  of  the  lymphatic  involvement ;  and 
third,  because  of  metastatic  formation  (dissemination  by  lymphatics 
and  hematogenous  metastases) . 

For  example :  Mammary  carcinoma  is  inoperable  when  the  tumor 
is  attached  to  the  thorax,  or  when,  even  in  small  tumors,  the  axillary 
and  the  supraclavicular  glands  are  affected,  or  when  small  nodules  are 
disseminated  throughout  the  skin  and  organic  structures  (liver,  lung) 
or  bony  metastases  have  formed. 

Cauterization  (with  the  thermocautery  or  with  caustics)  may  be 
used  for  the  purpose  of  destroying  or  removing  (cautery  snare) 
small  benign  tumors,  such  as  warts  or  pediculated  fibromata  of  the 
skin  and  mucous  membranes.  The  measure  is  likely  to  accomplish 
incompletely  the  intent,  and  in  malignant  processes  should  he  avoided, 
as  the  reaction  which  follows  presents  conditions  exceedingly  favorable 
to  increased  cellular  proliferation.  There  are  few  surgeons  who  have 
not  observed  an  unfortunate  outcome  of  this  sort ;  nor  are  these  oc- 
currences to  be  regarded  in  any  sense  as  recurrences  of  the  disease; 

1112 


THE  TKEATMENT  OF  TUMORS  IN  GENERAL   1113 

they  are  exacerbations  of  the  growth  induced  by  the  so-called  measure 
of  relief. 

Deligation  of  pediculated  tumors,  such  as  warts,  pediculated  fibro- 
mata, etc.,  is  destined  to  cause  necrosis  of  the  tumor  tissue.  The 
measure  does  not  often  remove  the  growth  in  its  entirety  and  the 
tumor  recurs. 

Light  therapy  is  a  modern  method  of  treatment,  the  outcome  of 
efforts  to  accomplish  bloodless  removal  of  tumors.  The  radio  tube  and 
certain  radioactive  substances  are  used  for  the  purpose. 

Absorption  of  the  rays  is  attended  with  inflammatory  and  degenera- 
tive changes.  In  the  latter,  cells  concerned  in  division  are  most  ac- 
tively influenced,  so  that  rapidly  proliferating  tumor  cells,  similar  to 
those  of  embryonic  tissue,  are  most  destructively  affected  (Cassimer,^ 
Lazarus,^  Hertwig^).     A  specific  action  on  tumor  cells  is  not  proved. 

In  the  X-ray  treatment  superficial  tumors  are  exposed  to  action  of  a 
low  vacuum  tube,  the  rays  of  which  do  not  penetrate  deeply  and  are 
readily  absorbed  by  the  tissues.  The  surrounding,  normal  skin  is 
protected  by  sheet  lead  and  the  tube  is  placed  ten  to  twenty  centi- 
meters from  the  lesion,  which  is  ''rayed"  for  from  five  to  twenty 
minutes  at  daily  intervals.  The  effect  upon  the  surrounding  skin 
should  be  limited  to  a  slight  erythema,  which  should  not  appear  until 
the  second  week  of  exposures.  The  dose  required  to  produce  this 
reaction  is  called  erythemodosis  or  normaldosis.  The  quantimeter  of 
Kionbock'*  is  a  useful  apparatus  in  this  connection.  Excessive  dos- 
age results  in  inflammation  and  necrosis  of  the  skin  (X-ray  burn). 
At  times,  chronic  skin  destruction  makes  its  appearance  after  months 
of  exposure.  It  taken  on  the  form  of  so-called  X-ray  ulceration,  which 
is  exceedingly  obstinate  and  is,  according  to  Glassmann,^  not  attended 
with  granulation  or  cicartrization,  because  of  the  degeneration  of  the 
muscularis  and  intima  of  the  blood  vessels  caused  by  the  destructive 
action  of  the  ray.  These  ulcers  are  often  converted  into  flat  carcinoma, 
which  develops  irrespective  of  whether  pathological  or  normal  skin 
has  been  "rayed."  In  a  few  instances,  spindle  cell  sarcoma  has  fol- 
lowed prolonged  by  repeated  exposure  to  the  ray  (Schumann,®  Por- 
ter,'^ V.  Haberer^). 

For  the  treatment  of  deeply  located  tumors,  hard  (high  vacuum) 
tubes,  the  ray  emanations  of  which  are  capable  of  great  penetration, 
are  used.  However,  even  these  rays  must  be  softened  by  the  inter- 
position of  aluminum  plates  (3  to  4  mm.  in  thickness)  in  order  to 
protect  the  skin  or  mucous  membranes.     The  technic  of  ''raying" 


1114  TUMORS 

deep  seated  tumors  has  been  worked  out  by  Kronig  and  Gauss,^  who 
showed  that  it  is  feasible  to  obtain  better  effects  by  the  use  of  large 
doses  of  the  ray  by  careful  filtration,  without  damaging  the  super- 
ficial parts,  especially  when  the  mass  is  approached  from  several 
aspects  of  the  body  in  sequence,  so  that  the  same  tissues  are  not  too 
frequently  exposed  en  route  (cross  fire  raying).  In  some  instances, 
tumors  of  the  stomach  and  gut  have  been  delivered  out  of  the  abdomen, 
sewed  into  the  wound,  and  rayed  with  seemingly  good  effect. 

Of  the  riado-active  substances,  radium  (usually  in  the  form  of  the 
bromide)  and  mesothorium  are  used  for  therapeutic  purposes.  The 
ray  energy  of  these  substances  (contained  in  small  metal  tubules) 
may  be  divided  into  three  groups,  of  which  those  possessing  the  least 
power  of  penetration,  a  and  b,  may  be  diverted  by  the  magnet.  The 
former  possesses  a  negative,  the  latter  a  positive,  polarity,  while  the 
ray  which  cannot  be  diverted,  the  c  ray,  possesses  a  power  of  penetra- 
tion greater  than  the  hardest  X-ray  tube.  During  the  process  of 
"raying,"  inflammation  and  necrosis  are  guarded  against  by  arresting 
the  a  and  b  rays  bj^  means  of  metal  plates  (lead,  silver,  or  brass). 
However,  the  secondary  rays  emanating  from  the  metal  filter  are  cap- 
able of  destroying  tissue,  so  that  it  is  necessary  to  afford  additional 
protection  by  the  interposition  of  rubber  or  pasteboard,  so  separated 
from  the  body  by  a  laj^er  of  cotton  that  the  preparation  does  not 
lie  close  to  the  skin  or  the  tumor.  Disregard  of  even  the  last  named 
precaution  is  followed  by  undesirable  effects.  The  use  of  small  doses 
30  to  50  mg.)  has  been  abandoned  since  Kronig  and  Gauss''  showed 
the  feasibility  of  ten  times  greater  doses.  However,  at  this  writing 
the  usual  dose  is  from  100  to  150  mg.,  as  the  use  of  larger  ones  pro- 
duces, at  times,  deep  ulceraiion  and,  not  seldom,  is  attended  with 
fever,  increased  pulse  rate,  malaise,  loss  of  appetite  and  weakness. 
In  a  case  of  carcinoma  of  the  uterus,  Bumm^°  demonstrated  penetra- 
tion to  the  depth  of  3  to  3i/o  cm.  Deeper  than  this,  carcinomatous 
tissue  was  not  affected ;  indeed,  Ranzi^^  claims  that  the  irritation 
caused  by  the  enfeebled  raj^  in  the  periphery  stimulates  cellular  pro- 
liferation. Broken  down  carcinoma  becomes  surrounded  by  nodular 
connective  tissue,  which  is  poor  in  cellular  elements  and  presents  hya- 
lin  degeneration.  E.  Rehn^^  inclines  to  the  belief  that  these  connective 
tissue  deposits  prevent  recurrence  of  carcinoma;  on  the  other  hand, 
Bumm^°  found  that  the  recurrence  always  occurred  beyond  the  ray 
nodule  and  extended  into  the  deeper  tissues.  Of  themselves,  these 
connective  tissue  masses  present  certain  dangers;  their  disintegration 


THE  TREATMENT  OF  TUMORS  IN  GENERAL   1115 

has  beeu  followed  by  ulceration  into  contiguous  organs  (bladder,  gut, 
pericardium)  and  into  large  blood  vessels,  causing  secondary  hemor- 
rhage. 

Final  judgment  of  the  value  of  ray  therapy  in  the  treatment  of 
tumors  in  general  and  of  carcinoma  and  sarcoma  in  particular  must 
as  yet  be  suspended.  This  is  also  true  as  to  whether  the  X-ray  and 
radium  should  be  used  separately  or  together.  The  increase  of  dosage 
made  possible  by  the  technic  of  Kronig  and  Gauss^  is  too  new  to 
permit  of  an  opinion  as  to  the  value  of  the  modification  in  dosage  to 
suit  particular  indications  presented  in  a  given  case. 

There  is  7io  doubt  that  superficially  located  tumors  may  be  made  to 
disappear  by  the  use  of  radiotherapy.  Doderlein^^  has  shown  that 
inoperable  tumors  may  be  made  susceptible  to  operable  relief  after 
the  use  of  the  ray.  In  malignant  growths  (aside  from  flat  skin  cancer) 
apparent  clinical  healing  has  not  heen  permanent  in  character;  on  the 
contrary,  recurrence  is  only  too  common.  Even  in  flat  skin  cancers, 
recurrences  develop  beneath  what  Lexer^*  calls  "the  deceitful  ray  scar 
where  proliferation  goes  persistently  on  until  an  inoperable  condition 
presents  itself."  Only  superficially  located  carcinomatous  lymph 
nodes  are  influenced  by  the  ray;  in  the  deeper  ones  the  cancer  takes 
its  undisturbed  onward  course,  sowing  metastases  as  it  goes. 

The  dangers  of  ray  treatment  are  great  and  encompass  both  local  and 
general  after  effects.  These  are  greater  in  operable  cases  than  after 
excision  and  the  treatment  does  not  give  as  much  security  against 
recurrence  as  obtains  after  extirpation.  In  addition  to  this,  delay 
always  encourages  the  formation  of  metastases. 

The  views  of  the  writer  may  be  regarded  as  coinciding  with  those  of 
Lexer^*  who,  after  painstaking  anah'sis  of  radiotherapy,  says  "Mj-  pre- 
vious standpoint  remains  unaltered ;  the  use  of  radiotherapy  is  adapted 
only  to  benign  tumors  and  to  inoperable  malignant  tumors;  on  the  other 
hand,  it  is  to  be  avoided  in  all  operahle  carcinomas  and  sarcomas. 
In  flat  cancer,  even  when  lymphatic  metastases  are  not  discernible, 
excision  should  be  practiced,  when  possible,  on  the  ground  of  its  cer- 
tainty,  speed,  and  simplicity  of  execution.  In  cases  of  inoperable 
malignant  disease,  radiotherapy  is  of  great  value;  although  complete 
relief  is  not  attainable,  progress  of  the  lesion  may  be  retarded  and  the 
measure  is  therefore  of  invaluable  service  to  the  doomed  host." 

In  the  care  of  inoperable  tumors  it  is  especially  desirable  that  the 
host  be  not  robbed  of  the  hope  of  recovery.  He  should  not  be  informed 
of  the  nature  of  his  affliction.     When  uncontrollable  factors  make  it 


1116  TUMORS 

impossible  to  conform  to  this  rule,  the  information  should  be  imparted 
to  the  patient  with  great  circumspection.  The  instances  in  which  this 
becomes  necessary  are  very  rare.  The  surgeon  must,  above  all,  be 
certain  that  he  is  in  possession  of  an  adequate  reason,  clear  to  himself, 
before  he  acts. 

The  local  treatment  of  inoperable  tumors  should  be  designed  to  main- 
tain the  comfort  and  happiness  of  the  patient  and,  when  ulceration  is 
present,  to  attain,  if  possible,  a  certain  degree  of  cicatrization.  Aside 
from  radiotherapy,  this  is  accomplished  at  times  by  injections  of  alco- 
hol, zinc  cJilorid  (20  to  50  per  cent)  and,  in  some  instances,  fol- 
lows the  administration  of  arsenic  and  iodin.  When  ulceration  is 
established,  the  use  of  antiseptic  protective  dressings  and  cleanliness 
tend  to  avoid  infection,  and  offensive  odors  may  be  controlled  by  the 
liberal  use  of  solutions  of  hydrogen  peroxid,  aluminum  acetate,  potas- 
sium permanganate,  etc.  For  the  same  purpose  the  thermocautery  or 
caustic  acids  may  be  employed.  Czerney^'*  uses  20  to  50  per  cent 
chlorid  of  zinc  gauze.  Fulguration  (lightning  treatment),  introduced 
by  Keating-Hart,^**  with  the  view  of  controlling  the  extension  of  inop- 
erable carcinoma,  has  not  proved  of  value  (Czerney,^''  Freund,^* 
Schultze,^®  Zimmern,^°  Nieuwenhuyse^^). 

After  Busch^^  (1866)  and  later  v.  Bruns-^  and  Biedert^*  had  ob- 
served that  sarcoma  disappeared  sequentially  to  an  attack  of  erysipe- 
las, and  that  carcinoma  was  reduced  in  size  under  similar  conditions, 
and  Fehleisen^'^  reported  recession  of  carcinoma  after  the  artificial 
induction  of  erysipelas,  many  workers,  notably  Cole}',^^  attempted  to 
accomplish  healing  of  malignant  tumors  by  the  seemingly  less  dan- 
gerous injection  of  sterile  cultures  of  streptococci  (mixed  with  prodi- 
giosus  toxin).'  Although  the  method  has  been  followed  by  the  dis- 
appearance of  tumors,  its  use  is  attended  with  so  much  general  dis- 
turbance and  the  measure  is  so  uncertain  in  its  action  that  it  should, 
even  in  inoperable  cases,  be  avoided  (Friedrich,-^  Czerney^*). 

The  pain  connected  with  tumor  growth  is  at  times  very  severe  and 
can  be  controlled  only  by  the  administration  of  morphia,  a  measure 
which  often  makes  bearable  the  last  portion  of  the  afflicted  life. 

When  erosion  hemorrhage  occurs  it  must  be  combatted  by  the  usual 
agents  employed  for  control  of  bleeding. 

The  general  treatment  is  directed  toward  combatting  incidental 
symptoms. 

Much  effort  has  been  expended  with  the  view  of  developing  a  speci- 
fic tumor  treatment,  but  with  little  success    (Keysser^'').     Ehrlieh^" 


THE  TREATMENT  OF  TUMORS  IN  GENERAL   1117 

indicated  the  way  in  this  direction  when  he  was  able  to  produce 
active  immunity  against  virulent  carcinoma  in  mice  by  inoculations 
with  less  virulent  cancer.  V.  Dungern^^  and  BorreP^  suggested  that 
recurrences  after  excision  and  extension  of  incompletely  removed 
malignant  growths  may  be  prevented  by  using  extracts  of  the  ex- 
cised tissue  for  the  purpose  of  active  immunization.  The  excised 
tissue  is  finely  divided,  ground  into  a  paste,  and  injected  subcutan- 
eously.  As  the  tumor  paste  contains  living  cells,  Delbet^^  warned  that 
the  method  might  be  followed  by  inoculation  metastases.  To  over- 
come this  BlumenthaP*  placed  the  preparation  into  the  incubator 
chamber  of  the  autolyzer  for  several  days.  Lexer^*  states  that  he  has 
seen  the  rapid  development  of  cachexia  follow  the  use  of  the  prep- 
aration which,  at  the  suggestion  of  Blumenthal,  he  injected  in  large 
doses  with  the  view  of  preventing  anaphylaxis.  Better  results  are 
reported  by  Stammler^'^  and  Keysser.^®  The  former  showed  that  the 
intravenous  injection  of  autolytes  is  more  effective  in  the  treatment 
of  inoperable  tumors  than  the  subcutaneous.  Keysser  uses  mechanical 
disintegration  of  the  cells  in  place  of  autolysis,  with  the  view  of  not 
only  utilizing  the  ferments,  which  are  the  main  constituents  of  Blumen- 
thal's  autolytic  preparation,  but  all  the  snhstarices  contained  in  tumor 
cells  which  may  he  of  value  in  active  immunization.  As  yet,  Keysser^® 
injects  the  preparation  subcutaneously  only  at  intervals  of  one  week. 
The  dosage  is  slowly  increased,  with  the  view  of  attaining  active 
immunity  without  provoking  harmful  reaction ;  the  treatment  is  con- 
tinued several  months. 

Efforts  have  also  been  made  to  discover  chemical  agents  which  act 
specifically  upon  tumor  growth  through  the  blood  without  deleterious 
effect  upon  normal  cells,  v.  Wassermann,  Keysser  and  M.  Wasser- 
mann,^"  working  with  a  preparation  consisting  of  eosin  and  selenin  in 
which  they  subcutaneously  injected  into  mice,  were  able  to  retard  the 
growth  of  mouse  tumors.  The  eosin  favored  the  deposit  of  the  selenin 
in  the  nuclei  of  the  tumor  cells.  However,  neither  this  preparation, 
nor  any  as  yet  available,  seems  to  have  a  similar  effect  in  the  human. 

BIBLIOGRAPHY 

1.  Casimer.     Med.  natui-wiss.  Arch,  ii,  1910,  with  lit. 

2.  Lazarus.     Berlin,  klin.  Woch.,  1914,  No.  5. 

3.  Hertwig.     In  Lazarus  Handb.  f.  Radiobiol.  and   Therap.,  Wiesbaden, 

1913. 

4.  KiENBOCK.     Radiotherapie,  Stuttgart,  1907. 

5.  Glassmann.     Fortsehr.  a.  d.  Geb.  d.  Rontgenstrahle,  ii,  1898-9. 


1118  TUMORS 

6.  ScHUMANK.     Arch.  f.  klin.  Chir.  Ixxxiv,  1907. 

7.  Porter.     The  Cancer  Coram,  of  Hai-vard  Univ.,  Boston,  1909. 

8.  V.  Haberer.     Wien.  klin.  Woch.,  1912,  No.  21. 

9.  Kronig  and  Gauss.     Deutsch.  med.  Woch.,  1913. 

10.  BuMM.     See  Hertwig  No.  3. 

11.  Ranzi.     See  Hertwig  No.  3. 

12.  E.  Rehn.     Beitr.  z.  klin.  Chir.  Bd.  66,  1910. 

13.  Doderleix.     Arzt.  Verein.  Miinchen.  Feb.,  1913. 

14.  Lexer.     Allgem.  Chir.  ii,  Stutigart,  1914. 

15.  CzERNEY.     Chir.  Kong.  Verhand.,  1900,  ii. 

16.  Keatixg-Hart.     See  Czerney  No.  15  and  No.  17. 

17.  Czerney.     Miinch.   med.   "Woch.,   1908;     also   1911;     also    Chir.   Kong, 

Verh.,  1908,  ii,  and  1909,  ii. 

18.  Freund.     Die  electrische  Funkenbehandlung,  Stuttgart,  1908. 

19.  ScHULTZE.     Miinch.  med.  Woch.,  1908. 

20.  ZiMMERN.     Les  actualites  med.,  Paris,  1909. 

21.  NiEUWENHUYSE.     Arch.  f.  klin.  Chir.  Bd.  90,  1909. 

22.  BuscH.     See  Coley  No.  26. 

23.  V.  Bruns.     See  Colev  No.  26. 

24.  Biedert.     See  Coley  No.  26. 

25.  Fehleisen.     See  Coley  No.  26. 

26.  Coley.     Boston  Med.  and  Surg.  Jr..  1908,  No.  6;    also  Surg.  Gyn.  and 

Obst.,  1911. 

27.  Friedrich.     Chir.  Kong.  Verh.,  1895,  ii. 

28.  Czerxey.     Miinch.  med.  Woch.,  1895. 

29.  Keysser.     Zeitschr.  f.  Cliemotherap.  Heft,  ii  and  xii,  1914. 

30.  Ehrlich.     Zeitschr.  f.   Artz.  Fortbild.,  1906;   also  Arb.   a.   d.  Inst.  f. 

Exp.  Therap.,  Jena,  1906. 

31.  V.  DuNGERN.     Das  Wesen  d.  bosartiiren  Gesehwiilste,  Leipzig,  1907. 

32.  BORREL.     Bull,  de  I'inst.  Pasteur,  1907. 

33.  Delbet.     See  Blumenthal  No.  34. 

34.  Blumenthal.     Med.  klinik.,  1910,  No.  39  and  No.  50;   also  Berlin,  klin. 

Woch.,  1913,  No.  50. 

35.  Stammler.     Verh.  d.  Deutsch.  Gesel.  f.  Chir.,  1913,  i. 

36.  V.  Wassermann,  Keysser  and  M.  Wassermann.     Deutsch.  med.  Woch., 

1911 ;    also  in  conjunction  with  Hansemann,  Verh.  d.  Berlin  med. 
Gesel.,  1911,  and  Berlin,  klin.  Woch.,  1912,  Heft.  i. 


CHAPTER  VI 

THE  SPECIAL  TUMOES 


CONNECTIVE  TISSUE  TUMORS 

Fibromata. — A  fibroma  is  composed  of  tissue  which  resembles  more 
or  less  elosel}'  one  of  the  many  types  of  normal  connective  tissue.  It 
is  often  round  in  form,  is  likely  to  be  large  and,  when  connected  with 
the  skin  or  mucous  membrane,  is  often  pediculated.  It  may  be  c&ti- 
geniial  and  occur  at  all  periods  of  life. 

Fibromata  grow  slowly  and,  like  all  tumors  that  extend  by  expan- 
sion, are  hetiign  in  char- 
acter. The  surrounding 
tissues  are  pushed  aside 
a  n  d  undergo  pressure 
atroph}',  even  when  bone 
is  involved.  Complete  re- 
moval is  followed  by  re- 
currence only  in  keloid. 

Fibromata  consist  of 
cells,  connective  tissue 
and  hlood  vessels.  The 
long,  often  curved,  nuclei 
and  the  narrow  proto- 
plasmic body  of  the 
former  cause  them  to  re- 
semble the  normal  cells  of 
connective  tissue ;  how- 
ever, their  tissue  often 
cells  which  are  rich  in  protoplasm  and  possess  large 
This  is  especially  the  case  when  proliferation  is  rapid. 
The  intercellular  spaces  are  single  or  united  in  the  form  of  fibers. 
These  are  closel}'  apposed  to  each  other  or  are  loosely  separated, 
which  accounts   for  the  variations  in   consistence   of   this   class   of 

1119 


Fig.  529. —  Hard  Fibroma. 


contains 
nuclei. 


I 


1120 


TUMORS 


tumors.  On  section,  the  glistening,  hard  fibroma  {desmoid)  presents 
clearly  visible,  firmly  interwoven,  coarse  fibers,  while  the  soft  variety 
{fibroma  molluscum)  presents  loosely  woven,  fine  single  fibers  separ- 
ated by  fluid  mixed  with  lymphocytes  and  leukocytes,  which  appear 
on  the  sectional  surfaces  in  the  form  of  soft  masses  (Figs.  529  and 
530). 

Although  fibromata  are  usually  intimately  associated  with  the  sur- 
rounding connective  tissue,  they  are  easily  separated  from  it.  When 
the  tumor  originates  from  the  connective  tissue  of  a  muscle,  it  also 
contains  muscle  fibers,  and  when  they  arise  from  nerves  or  from 
glandular  organs,  they 
contain  nerves  fibers  and 
gland  tissue.  Periosteal 
fibromas  often  contain 
bone  tissue,  which  de- 
velops from  the  prolif- 
erating connective  tissue 
in  the  same  wa^'  as  it  does 
from  normal  periosteum. 

As  far  as  the  congenital 
tumors  of  the  skin  and 
nerves  and  those  covering 
cerebral  hernia  or  spina 
bifida  are  concerned,  fibro- 
mata probably  oive  their 
origin  to  certain  faults 
in  development.  Many 
forms  evince  an  heredi- 
tary disposition  (elephan- 
tiasis nervorum  and  keloid),  while  others  seem  to  develop  in  connection 
with  inflammatory  proliferation. 

Fibromata  may  be  divided  into  two,  not  very  clearly  defined,  groups. 
In  one  group  the  proliferation  attendant  upon  chronic  inflammatory 
processes  of  the  skin  and  subcutaneous  tissues  and  upon  congenital 
hypertrophies  (partial  giantism)  shows  a  tendency  toward  tumor-like, 
elephantiasic  formation.  When  these  are  circumscribed  and  clearly 
outlined  against  their  surroundings  (as  for  instance,  in  the  lobulated 
or  pediculated  form),  they  are  regarded  as  lobulated  elephantiasis  and 
are  classed  with  the  flbromata.  In  the  other  group  it  is  difficult  to 
separate  the  process  from  the  forming  of  fibrous  sarcomata,  which 


Fig.   530.- 


SoFT  Fibroma  Developing  in  Sub- 
cutaneous Tissue. 


THE  SPECIAL  TUMORS 


1121 


develop  from  the  beni^  form.  When  the  newly  formed  tissue  is  rich 
in  cells  compared  to  the  intercellular  stroma,  and  when  the  cells  do  not 
possess  the  characteristics  of  those  of  connective  tissue,  but  present  a 
preponderance  of  protoplasm  with  large,  oval  nuclei  which,  by  their 

rapid  division,  dis- 
play great  prolifera- 
tive capacity,  the 
tumor  is  properly 
classified  with  the 
fibrosarcomata. 

The  hJood  vessels 
are  developed  to  a 
varying  extent. 
When  the  blood  ves- 
sels consist  simply 
of  a  rich  network  of 
irregular  tubules 
with  a  layer  of  endo- 
thelium (as  is  often 
seen  in  nasal  and 
nasopharyn  geal 
poh'pi),  the  tumor 
is  called  fibroma 
telangi  e  ct  at  icum; 
when  larger  vascu- 
lar spaces  are 
present,  the  term 
fibroma  cavernosum 
is  used.  Fibroma 
lymphangieciaticum 
is  profusely  sup- 
plied with  dilated 
lymph  vessels. 

Nutritive  disturb- 
ances, especially  in 
hard  fibromata,  in 
which  pressure  from  the  surrounding  tissue  obliterates  the  blood 
vessels,  cause  liquefactimi  of  insular  areas  of  the  proliferated  tissue, 
which  is  converted  into  a  mucoid  substance  (fibroma  myxomatodes) 
and  into  cavities  (fibr&nia  cijsticum). 


Fig.  531. —  Fibromata  Molll'sca  of 
THE  Skin  axd  Sarcoma  of  the 
Left  Axillary  Fossa. 


1122 


TUMORS 


Mixed  forms  of  fibromata  are  found  in  the  subcutaneous  and  sub- 
serous tissues,  fihrolipomata;  and  in  the  uterus,  fihromyomata. 

Fibromata  occur  frequently  and  ai:)pear  in  many  situations,  though 
some  portions  of  the  body  are  more 
often  the  seat  of  these  growths  than  are 
others. 

Classified  on  the  basis  of  the  kind  of 
tissues  involved,  there  are  eight  kinds 
of  fihromata. 

I.  Fibromata  of  the  shin  are  sub- 
divided into  five  hinds. 

A.  The  soft  wart  (fleshy  wart,  ver- 
ruca cornea)  is  a  small,  round,  usually 
pigmented  formation  with  a  broad 
pedicle,  which  has  a  smooth  or  wrinkled 
surface  and  is  either  congenital  or  de- 
velops early  in  childhood  from  con- 
genital pigmented  moles  and  may 
become  a  large  pediculated  or  lobulated 
soft  fibroma. 

They  are  often  found  on  the  face 
and  nech  or  coexist  with  fibromas  of  the 
nerves,  and  are  frequently  distributed 
over  the  entire  surface  of  the  body. 
They  are  often  associated  with  numer- 
ous flat  and  warty  nevi  and  large 
fibromata. 

Judging  from  their  structure  they 
are  soft  fibromata  which,,  according  to 
Soldan,^  originate  from  the  connective 
tissue  cells  of  the  nerves  of  the  skin. 

Fibromata  of  this  sort  are  easily  dif- 
ferentiated from  the  warts  found  on 
the  hands  (especially  those  of  chil- 
dren). The  latter  are  autoinoculable 
and    develop    the   papillae    and    their 

epidermis,  which  causes  them  to  present  small,  smooth  or  rough  pro-i 
tuberances  with  irregular  elevations.  j 

B.  Fibromata  mollusca  is  a  term  applied  to   nodular,   painless; 


Fig.  532. —  Multiple  Neuro- 
fibromatosis (v.  Reckling- 
hausen's   Disease)     (Pusey). 


THE  SPECIAL  TUMORS 


1123 


tumors  of  the  skin,  which  are  usually  multiple,  vary  in  size,  are  often 
pediculated  and,  according  to  v.  Recklinghausen,-  originate  from  the 
nerves  of  the  skin  and,  therefore,  should  be  classed  with  the  nerve 
fibromata.    They  often  contain  a  fine  plexus  of  nerve  fibres. 

C.  The  term  lohulated  elephantiasis  is  applied  to  a  number  of 
kinds  of  fibrous  proliferative  skin  processes  which  are  characterized 
by  the  formation  of  long  pendulous  masses,  folds,  flaps  or  sacs  (Fig. 
533).     In  part  they  belong  to  the  domain  of  the  lymphangiomas  and 


Fig.  533. —  Lobulated  Elephantiasis   (Puscyj. 

hemangiomas  (elephantiasis  lymphangiectatica,  elephantiasis  heman- 
giectatica)  ;  in  part  they  are  soft  fihromas  which,  like  the  nodular  skin 
fibromas,  consist  of  the  connective  tissue  of  the  nerves  of  the  skin,  but 
the}'  are  also  richly  supplied  with  blood  and  lymph  vessels  (v.  Es- 
march  and  Kulenkampff^). 

The  nerve  form  of  elephantiasis  is  congenital  or  develops  early  in 
childhood  from  soft  skin  fibromas.  Tliese  tumors  are  seen  (most  often) 
on  the  face,  head,  neck  and  shoulder  (Fig.  533),     They  are  covered 


k 


1124  TUMORS 

by  thin,  wrinkled,  often  pigmented  skin  and  are  more  or  less  covered 
with  hair. 

In  many  of  these  cases,  the  elephantiasic  fibrous  formation  is  associ- 
ated with  additional  tumors  that  may  be  classed  with  nerve  fibromata, 
such  as  soft  warts,  fibromata  mollusca,  the  plexiform  neuromata  in  the 
base  of  lobulated  growths,  and,  finally,  fibromata  of  large  nerves,  all  of 
which  V.  Bruns*  groups  under  the  general  term  of  elephantiasis  nerv- 
orum. Most  of  these  forms  are  accompanied  by  congenital  abnormali- 
ties of  the  skin,  which  appear  in  the  form  of  large  and  small,  mostly 
flat,  light  brown,  pigmented  areas.  The  white  warts  develop  into  large 
fibromas  and  these  enlarge  into  lobulated  formations.  According  to 
Soldan,^  pigmented  moles  represent  the  preliminary  stage  to  the  soft 
wart  and  ihultiple  fibromata  of  the  skin.  This  author  also  seems 
to  have  shown  that  the  cell  columns  of  these  pigmented  nevi  are 
neither  of  epithelial  nor  of  endothelial  origin,  but  are  proliferated  cells 
of  the  connective  tissue  of  the  nerves  of  the  skin,  a  conception  sup- 
ported by  the  clinical  picture,  as  the  flat,  more  rarely  verrucous  nevi, 
soft  warts,  fibromas  of  the  skin  and  of  the  deeper  nerves  appear  to- 
gether. 

Independent  lobulated  elephantiasic  growths,  developing  from 
inflammatory  hyperplasias  in  connection  with  repeated  attacks  of 
erysipelas,  acne  rosacea  or  from  infection  with  filaria  sanguinis,  do 
not  belong  to  the  nerve  form  of  these  tumors. 

D.  Hard  fibromata  of  the  skin  are  less  often  congenital  than  the 
soft  variety.  They  appear  in  the  form  of  small,  hard  nodules  {hard 
wart)  or  as  a  slowly  growing  fungoid  growth  with  a  long  thin  pedicle 
{fibroma  pendulum).  The  latter  form  appears  at  all  periods  of  life 
and  is  frequently  found  on  the  back,  the  inner  side  of  the  upper  arm, 
and  on  the  thigh.  Fibromas  of  this  sort  also  present  transitional  forms 
tending  toward  the  soft  variety.  On  section,  the  tumor  is  sharply 
defined  against  the  subcutaneous  fat,  and  its  surface  is  covered  by  a 
thin  layer  of  subepithelial  connective  tissue. 

The  diagnosis  of  fibromas  of  the  skin  is  not  difficult.  When  section 
or  the  microscope  reveals  the  epidermis  concerned  in  proliferation, 
the  tumor  should  be  classed  in  the  fibro^epithelial  group.  Elephanti- 
asic growths  which  are  compressible  are  closely  allied  to  lymphangi- 
omas and  hemangiomas  or  belong  to  those  classes  of  tumors. 

The  treatment  consists  of  extirpation,  unless  the  size  or  the  location 
of  the  tumor  renders  this  impracticable.  Extensive  elephantiasic 
tumors  may  be  removed  in  sections.     In  the  congenital  form  the  con- 


I 


THE  SPECIAL  TUMORS 


1125 


nective  tissue  proliferation  of  the  nerves  must  be  thoroughly  removed, 
or  they  will  recur.  Residual  defects  must  be  closed  by  transplants 
or  by  plastic  methods  of  repair. 

E.  Keloids  are  a  special  form  of  fibroma  of  the  skin.  They  are 
firm,  comparatively  rich  in  cells,  and  closely  fibrillated;  the  fibers 
often  i^resent  thick,  apparently-  homogeneous,  collagenic  trabeculae. 

They  appear  as  painless,  reddish,  hard  elevations  of  the  skin  or  as 
nodular  tumors  of  considerable  size,  or  they  may  be  ai'ranged  in  the 
form  of  the  shears  of  a  crab.     They  may  be  single  or  multiple. 

As    pro  lif  eration 
takes  place  only  from^ 
the  reticular  layer  of 
the    skin    and    never 
extends     into     the 
deeper    tissues,    the 
tumor  always   moves 
with    the    skin     and 
may  be  lifted  with  it. 
The  shining,  reddish 
surface  of  the  growths 
is  due  to  a  thin  laj'er 
o  f    vascular     cutis 
covering  them,  which 
mei'ges  into  the  sur- 
rounding normal  skin 
and  is  sharply  defined 
against   it.      The   ex- 
pansive extension  of 
keloids  displaces   the 
neighboring      tissues, 
which    accounts    for 
the  absence  of  elastic  fibers  and  hair  follicles  in  this  class  of  tumor. 
1     Most  keloids  develop  in  the  course  of  the  healing  of  a  wound  which, 
i  instead  of  cicatrizing,  becomes  the  site  of  a  tumor.     These  tumors 
(develop  very  slowly  and  at  the  end  of  several  months  reach  the  limit 
of  their  growth.     Burns  of  the  third  degree  and  injuries  produced  by 
caustics  seem  to  present   conditions  favorable  to  keloid  formation, 
though  they  also  follow  suppurative  processes,  healing  by  primary 
union,  ulcers,  vaccination  wounds,  contusions    (from  whip  wheals) 


Fig.   534. —  Keloids  of  Ear    (Symmers,  Bellevuo 
Hospital  case). 


1126 


TUMORS 


and  hypodermic  punctures  (Brandle'').  Keloids  originating  from 
scars  were  for  a  long  time  differentiated  from  those  arising  spontane- 
ously. However,  the  structure  of  both  forms  (aside  from  the  absence 
of  papillary  bodies  in  scar  keloid  —  Trawinski")  is  the  same.  It 
would  seem  that  the  development  of  spontaneous  keloid  is  only  appar- 
ent, and  that  they  arise  from  unnoticed  small  wounds  or  injuries  of  the 
cutis  without  rupture  of  the  epidermis. 

The  hyperirophic  scar  which  appears  as  a  reddish,  usually  tender, 
smooth  or  irregular  mass,  corresponding  to  the  conformation  of  the 
original  wound,  is  not  a  keloid.  This  is  not  a  tumor,  but  consists  of  an 
overproduction  of  scar  tis- 
sioe,  which  not  rarely 
occurs  in  connection  with 
inflamed  wounds.  Histo- 
log'icallj'',  scar  tissue  of  this 
sort  consists  of  wavy,  loose 
connective  tissue  cells  and 
frequently  a  cellular  infil- 
trate surrounding  hair  fol- 
licles, characteristics  which 
render  differentiation  from 
keloid  very  eas}^  Scar 
tissue  of  this  kind  tends  to 
increase  in  size. 

Keloids  occur  most  fre- 
quently upon  portions  of 
the  body  likelj'  to  be  in- 
jured, though  special  parts 
are  involvel  with  particu- 
lar frequency,  i.  e.,  lobes  of  the  ears  following  puncture  for  earrings, 
the  site  of  vaccination  (upper  arm),  the  skin  of  the  face  and  the 
breast,  the  palms  of  the  hands  and  the  soles  of  the  feet.  Trawinski' 
observed  a  case  of  disseminating  keloid  (apparently  spontaneous) 
which  extended  over  the  breast  and  back.  The  lesion  occurs  most 
often  in  middle  life  and  is  common  in  negroes. 

The  distinguishing  peculiarity  of  keloids  is  their  tendency  to  recur. 
This  happens  even  after  complete  excision,  sopietimes  in  a  few  weelcs, 
irrespective  of  whether  the  wound  is  sutured,  covered  by  transplants, 
or  allowed  to  granulate.  At  times,  they  appear  at  the  site  of  the 
stitch  holes.     Failure  to  return  after  removal  has  occurred.     Despite 


Fig.  53.5. —  Keloid,  Suowixg  Large  Connective 
Tissue  Fibers  and  Nuclei  of  Fibrous  Tissue 
Cells. 


THE  SPECIAL  TUMORS  1127 

this  tendency  to  recurrence,  keloids  are  not  malignant  tumors  and  do 
not  lead  to  the  formation  of  metastases. 

Keloid  formation  is  often  multiple.  The  affected  person  may 
develop  other  similar  growths  at  the  site  of  any  injury,  provided  the 
trauma  penetrates  the  cutis.  On  the  other  hand,  the  existence  of  a 
keloid  does  not  preclude  normal  repair  of  wounds  in  other  remote  por- 
tions of  the  body.  This  permits  the  assumption  of  a  disposition 
toward  keloid  formation,  which  in  some  people  is  local  and  in  others 
general.  The  occasional  demonstration  of  hereditjj  would  also  argue 
for  a  special. tendency.  In  other  regards  the  causation  of  keloid  is 
unknown. 

The  diagnosis  of  keloid  does  not  present  difficulties.  It  may  per- 
haps be  mistaken  for  hypertrophic  scar  tissue  or  for  the  flat  form  of 
skin  fibrosarcoma. 

The  treatment  is  confronted  with  the  tendency  the  lesion  has  to 
recur.  Excision,  therefore,  does  not  present  an  attractive  outlook, 
especially  when  the  growth  is  extensive.  Goldmann's^  contention  that 
immediate  transplantation  of  epidermal  flaps  prevents  recurrence,  on 
the  ground  that  the  adherence  of  the  flap  prevents  atypical  prolifera- 
tion, is  7iot  home  out  hy  clinical  experience. 

Of  the  various  chemical  substances  injected  into  keloid  tissue,  with 
the  view  of  causing  its  disappearance,  the  fifteen  per  cent  alcoholic 
solution  of  //( iosi)}amin  (or  the  ten  per  cent  watery  solution  of  glycerin- 
thiosinamin  of  Duclaux*),  first  used  by  Hebra^  (1892),  is  of  value. 
After  several  injections  of  1  c.cm.  of  the  solution,  the  nodules  assume 
a  bluish  color  and  begin  to  shrink.  In  large  keloids  or  in  extensive 
scar  tissue  the  treatment  is  carried  on  for  months.  The  injections  are 
best  made  directly  into  the  nodules ;  they  are  rather  painful.  As  the 
method  at  least  produces  diminution  in  the  size  of  the  tumors,  it  is  to 
be  preferred  to  the  very  uncertain  excision.  Fihrolysin,  which  is 
soluble  in  water,  is  a  double  salt  of  thiosinamin  and  sodium  salicylate. 
Brandenburg's^"  experimental  work  would  seem  to  cast  a  doubt  as  to 
the  effectiveness  and  harmlessness  of  the  agent.  The  latter  is  also 
questioned  by  Sidorenko.^^  Grosse^^  reports  seeing  toxic  effects 
produced  by  it. 

II.     Fibromata  of  the  subcutaneous  tissues  are  not  as  frequent  as 

,  those  of  the  skin.     They  appear  at  all  periods  of  life  and  in  all  por- 

'  tions  of  the  body,  develop  slowly,  and  often  reach  considerable  size. 

The  superimposed  skin  is  normal  in  appearance,  and,  as  the  tumor  is 


1128  TUMORS 

encapsulated,  is  readily  movable  over  it.  They  cause  disturbances  by 
pressure  on  contiguous  nerves. 

The  diagnosis  rests  on  their  slow  growth,  their  hardness  and  their 
mobility. 

They  are  extirpated  with  ease. 

III.  Fibromata  of  mucous  membranes  are  usually  multiple  and 
occur  most  frequently  in  the  nose.  The  tumor  tissue  is  usually  loosely 
woven  and  edematous,  but  may  be  hard.  Those  of  the  nose  are  pedi- 
culated  or  lobulated,  often  contain  large  blood  vessels,  and  are  covered 
with  a  layer  of  epithelium  and  one  of  connective  tissue.  -They  are  not 
easily  distinguished  from  inflammatory  polypoid  mucous  membrane 
hyperplasias. 

Similar,  though  somewhat  smaller,  multiple  tumors  are  found  in  the 
larynx  and,  at  times,  in  the  gastrointestinal  canal,  in  the  urethra,  and 
in  the  biliary  passages.  They  also  appear  in  the  mucosa  of  the  mouth 
(on  the  tongue,  in  the  floor  of  the  mouth,  and  on  the  gums)  in  the 
form  of  small,  smooth,  circumscribed  fibromata. 

Nasal  and  laryngeal  polypi  are  removed  with  specially  constructed 
forceps  or  with  the  wire  snare.  At  times  preliminary  operative  dis- 
lodgment  of  the  nose  or  laryngofissure  for  purposes  of  approach  are 
necessary. 

IV.  Fibromata  of  fascice  and  aponeuroses  are  hard,  nodular,  pain- 
less tumors  which  are  multiple  or  appear  singly  and  are  frequently 
found  in  the  abdominal  wall  {desmoids  of  the  abdominal  wall).  They 
arise  most  often  from  the  anterior,  but  may  arise  from  the  posterior 
sheath  of  the  rectus  muscle,  the  aponeurosis  of  the  external  oblique, 
from  the  fascia  transversalis,  and  the  linea  alba.  Fibromata  of  this 
sort  grow  very  slowly,  though  at  times  they  develop  more  rapidly 
during  pregnancy.  They  often  reach  the  size  of  the  adult  fist,  or 
larger,  separating  the  muscle  fibers  as  they  grow.  The  fascia  of  the 
affected  muscle  is  infiltrated  by  connective  tissue  proliferation. 

In  a  few  cases,  several  tumors  of  this  nature  have  developed  sequen- 
tially in  the  abdominal  wall  of  the  same  case,  although  recurrence  after 
extirpation  is  rare  (Pfeiffer"). 

The  fact  that  women  who  have  borne  children  are  most  often 
affected  suggests  a  traumatic  causation  (unimportant  ruptures) . 

In  making  the  diagnosis,  the  seat  of  the  tumor,  in  the  abdominal 
wall,  is  important.  When  the  abdomen  is  held  tense  the  hard  char- 
acter of  the  growth  and  its  mobility  is  easily  discerned. 


THE  SPECIAL  TUMORS 


1129 


Extirpation  of  the  tumor  should  be  followed  by  careful  repair  with 
the  view  of  obviating  hernia  ahdominalis. 

Fibromata  occurring  in  the  neck  are  honored  with  a  special  clinical 
classification.  They  arise  from  the  aponeuroses  that  sheathe  the  great 
vessels  and  from  the  intermuscular  sheaths.  At  times  a  fibroma  arises 
from  the  periosteum  of  the  anterior  portion  of  the  bodies  of  the 
vertebrae  (de  Quervain^^). 

V.  Fihromata  of  the  periosteum  originate  most  often  from  the 
upper  and  lower  jaws  and  from  the  vault  and  hase  of  the  skull.    They 


Fig.  536. —  Fibrous  Nasopharyngeal  Polyp,  which  has  Invaded  the  Antrum 

OF   HlGHMORE. 


occur  almost  exclusively  in  childhood,  are  of  the  hard  form,  and  are 
likely  to  be  extremely  vascular.  At  times  they  contain  hone  tissue 
evolved  from  the  periosteum. 

Fihromata  of  the  jaws,  together  with  the  several  varieties  of  sar- 
coma, form  a  part  of  the  clinical  group  of  epules,  i.  e.,  tumors  attached 
to  the  gums.  The  fibromata  arise  from  the  periosteum  of  the  alveolar 
processes  and  protrude,  in  the  form  of  small  nodules,  between  the 
teeth.  They  are  covered  bj^  mucous  membrane,  and  do  not  give  rise 
to  symptoms  until  large,   or  until   ulceration   and  bleeding   occur. 


1130 


TUMORS 


Tumors  of  this  class  also  arise  from  other  portions  of  the  jaws,  espe- 
cially the  upper,  where  they  form  lobulated  or  round  masses.  Central 
fibromata  also  develop  in  the  jawbones.  In  this  situation  they  orig- 
inate from  the  connective  tissue  of  the  marrow,  the  vessels,  or  the 
nerves;  possibly  also  from  displaced  embrj^onic  teeth.  Thej^  gradu- 
ally thin  out  and  dilate  the  corticalis,  through  which  they  ultimately 
break,  and  invade  the  maxillary  sinus. 

Fibrous  nasopharyngeal  polypi  is  a  term  applied  to  hard  fibromata 
found  usually  in  the  male  sex  between  the  ages  of  fifteen  and  twenty- 
five,  in  the  dome  of  the  pharynx,  i.  e.,  at  the  base  of  the  occipital  bone 
and  its  vicinity.  They  arise 
from  the  periosteum  and  dis- 
place the  mucous  membrane  in 
the  direction  of  least  resistance. 
At  first  they  occlude  the  pos- 
terior nares  and  gradually  in- 
vade the  nasal  fossae.  As  they 
make  increased  pressure  they 
widen  the  pterj^gopalatine  fossa 
and  cause  atrophy  of  the  bones, 
so  that  the  tumor  masses  are 
caused  to  invade  the  accessory 
sinuses  and  the  cranial  cavity 
(Figs.  536-537).  When  these 
tumors  ulcerate,  severe  hemor- 
rhage is  likely  to  occur,  as  they 
are  often  nourished  by  blood 
vessels  of  considerable  size. 

N  a  s  o  p  h  arj-ngeal    fibromata 
must  be  differentiated  from  malignant  growth,  which  is  not  always 
easy. 

Preliminary,  temporary  resection  of  the  superior  maxilla  is  neces- 
sary before  complete  extirpation  can  be  accomplished,  a  measure  of 
considerable  magnitude. 

VI.  Of  the  glandular  organs,  the  mammary  gland  is  most  often 
the  seat  of  fibromata  which,  in  this  situation,  contain  glandular  ele- 
ments (see  adenoma). 

The  appearance  of  fibromyomata,  fibrolipomata,  and  fibromata  in 
the  kidney  is  ascribed  to  disturbances  in  development.     They  often 


Fig.  537. —  The  Same  Tumor,  Showing 
Invasion  op  the  Skull  Cavity. 


THE  SPECIAL  TUMORS 


1131 


arise  from  the  kidney  tubules  and  extend  into  the  pelvis  or  become 
subcapsular  and  at  times  attain  to  great  size. 

VII.  Fibromata  of  the  nerves  {fibromata  7iervorum)  are  very 
common  tumors  which  appear  to  an  innumerable  extent.  They  con- 
sist of  soft,  rather  cellular,  fibers  which  originate  from  the  connective 
tissue  of  nerves  {endoneurium  and  perineurium) .  Their  growth  dis- 
places the  nerve  fibers,  but  these  do  not,  of  themselves,  proliferate, 
though  they  often  occupy  a  portion  of  the  new  growth.  When. the 
fine  network  of  the  nerves  of  the  skin  is  involved,  the  lesion  makes  its 
appearance  in  the  form  of  multiple  soft  fibromata  or  of  elephantiasic 
lobules  of  the  skin,  which  latter  are  often  of  microscopic  size. 

When  the  larger 
nerve  trunks,  in- 
cluding those  of 
the  sympathetic 
system  and  the 
roots  of  the  cranial 
and  spinal  nerves, 
are  involved  the 
process  may  ap- 
pear in  the  form 
of  single,  spindle 
shaped  or  large, 
nodular  masses. 

The  small  single 
fibromata  of  subcu- 
taneous and  cu- 
taneous nerves  are 
called  tuhercula 
dolorosa. 

AVhen  only  a  re- 
stricted zone  of  a  subcutaneous  nerve  is  involved,  coarse,  wreath- 
like nodules  of  elongated,  twisted  bands  or  plexuses  are  formed, 
that  are  more  or  less  circumscribed  and  often  covered  with  a  layer 
of  bulbous  skin  nerves  or  terminate  in  large  skin  flaps  (elephan- 
tiasis). Tumors  of  this  class  are  called  plexiform  neuromata  (neuro- 
fibromata  cirsoides  of  v.  Bruns*)  (Figs.  538-539).  The  plexiform 
neuromata  of  smaller  nerves  cannot  be  unraveled ;  in  the  bigger  ones 
the  course  of  the  nerve  may  be  followed  from  its  normal  side  and 
slowly  dissected  out  (Strauss^^). 


Pig.  538. —  Xerves  Dissected  Free  from  a  Subcutane- 
ous Plexiform  Neuroma  Removed  from  the  Occipital 
Region  of  a  Child. 


1132 


TUMORS 


Palpation  reveals  the  presence  of  small,  hard  lobules  or  large 
nodules,  and  at  times  the  trabeculae  can  be  felt.  The  superimposed 
skin  is  usually  pigmented. 

Plexiform  neuromata  begin  early  in  childhood  and  are  often  con- 
genital. The  larger  forms  of  tumor  do  not  appear  until  middle  life. 
However,  even  the  latter  may  begin  early  in  life,  but  do  not  attain 
visible  proportions  until 
later,  as  a  part  of  a 
general  elephantiasis 
nervorum. 

The  cause  of  nerve 
fibromata,  like  that  of 
all  nerve  elephantiasis, 
must  be  looked  for  in 
disturbances  of  develop- 
ment which,  perhaps  as 
the  result  of  irregular 
division  and  arrange- 
ment of  yierve  connective 
tissue,  permits  of  inde- 
pendent  proliferation 
(Ribbert^«).  This  view 
is  supported  by  the  fact 
that  the  lesion  appears 
early  in  life  and  is 
usually  multiple,  which 
indicates  the  influence  of 
heredity  or  at  least  an 
hereditary  disposition, 
to  which  may  be  added 
the  fact  that  it  is  not  uncommon  to  find  several  members  of  the  same 
famil}^  affected  with  a  certain  form  of  nerve  elephantiasis  (i.  e.,  either 
nerve  fibromata,  soft  skin  fibromata,  or  soft  warts). 

The  clinical  importance  of  nerve  fbromata  varies  tcidehj.  Like  the 
molluscum  formations  of  the  skin,  they  at  times  attain  considerable 
size  without  causing  disturbances.  The  most  common  symptom  is 
pain,  which  radiates  from  the  site  of  the  tumor,  is  distributed  over  the 
terminal  area  of  the  nerve,  and  is  increased  by  manipulation  of  the 
growth.  Functional  disturbances  are  usually  slight,  and,  when  pres- 
ent, consist  of  modification  of  sensation  and  motion.     At  times,  tumors 


Fig.  539. —  Plexiform  Neuroma  of  the  Sub- 
cutaneous Ner\^s  of  the  Thorax  in  a  Boy 
Eight  Years  of  Age. 

The  tumor,  about  as  large  as  a  small  plate,  was 
flat  and  covered  by  normal  skin,  wliich,  however, 
was  somewhat  adherent  to  it.  Surface  of  tumor 
somewhat  nodular.  Pain  upon  jDressure.  Tumor 
well  encapsulated  and  not  attached  to  underlying 
structures.  Many  flat,  pigmented  moles  in  the 
skin  adjacent  to  the  tumor. 


THE  SPECIAL  TUMORS  1133 

make  pressure  on  contiguous  uer^'es  or  upon  restricted  areas  of  the 
brain  and  spinal  cord. 

When  a  .single  tumor  is  removed  it  does  not  return.  However,  its 
extirpation  does  not  preclude  the  appearance  of  similar  tumors  else- 
where in  the  body  (v.  Biingner^').  According  to  Garre,'*  in  12 
per  cent  of  the  cases  of  general  fibromatosis,  sarcoma  develops  from 
single  nodules.     These  Garre^^  calls  secondary  malignant  neuromata. 

The  diagnosis  of  nerve  fibromata,  -when  multiple  and  distributed 
over  large  areas,  is  not  difficult.  When,  however,  single  nodules  are 
connected  with  deeply  located  nerves,  doubt  may  arise,  as  the  pressure 
of  liponiata  and  lymph  node  sivcllings  may  also  cause  radiating  pains. 
However,  cases  afflicted  with  nerve  fibromata  also  usualh'  present  the 
significant,  disseminated,  light  brown,  pigmented  spots. 

The  treatment  consists  of  extirpation  of  the  tumors  when  the  mag- 
nitude of  the  process  does  not  render  the  procedure  impracticable.  In 
plexiform  neuromata,  superimposed  elephantiasic  skin  is  also  excised. 
When  thickened  nerve  tissue  is  left  hehind  the  growths  recur. 

VIII.  Fibromata  of  the  peritoneum  originate  from  the  subserous 
connective  tissue  of  the  mesentery.  They  grow  very  slowh^  and 
develop  into  large,  hard,  somewhat  nodular  tumors,  which  give  rise  to 
symptoms  according  to  their  location. 

Extirpation  may  be  made  difficult  by  their  adherence  to  the  gut,  so 
that  resection  of  the  latter  becomes  necessary.  This  may  also  be 
demanded  when  large  areas  of  the  mesenter^^  are  involved. 

BIBLIOGRAPHY 

1.  SOLDAN.     Arch.  f.  klin.  Chir.,  Bd.  59,  1899. 

2.  V.  Recklixgiiausen.     Berlin,  1882. 

3.  V.   EsMARCH  and  Kuhlexkampff.     Die  elepliant.   Formen,   Hamburg, 

1885. 

4.  V.  Bruxs.     Beitr.  z.  klin.  Chir.,  Bd.  8,  1892. 

5.  Braxdle.     Dermatol.  Zeitschr.,  Bd.  16,  1909. 

G.     Trawixski.     Arch.  f.  Dermatol,  and  SyphiL,  Bd.  96,  1909. 

7.  GoLDMAXX'.     Quoted    by    Lewandowski,    Therap.    d.    GegenT^art,    1903, 

with  lit. 

8.  DucLAUX.     Quoted  by  Lewandowski,  Therap.  d.  Geffenwart.  1903,  with 

lit. 

9.  Hebra.     Quoted  by  Lewandowski,  Therap.  d.  Gegenwart,  1903,  with  lit. 

10.  Brandexburg.     Arch.  f.  klin.  Chir.  Bd.  89,  1909. 

11.  SiDOREXKO.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  110,  1911. 

12.  Grosse.     Miinch.  med.  Woch.,  1908. 

13.  Pfeiffer.     Beitr.  z.  klin.  Chir..  Bd.  44,  1904. 

14.  de  Quervaix.     Arch.  f.  klin.  Chir.,  Bd.  58,  1899. 

15.  Strauss.     Deutsch.  Zeitschr.  f.  Chir..  Bd.  83.  1906. 

16.  RiBBERT.     Die  Lehre  der  Geschwiilste.  Wiesbaden,  1902,  with  lit. 

17.  V.  BrxGXER.     Chir.  konsf.  Verb.,  1897,  ii. 

18.  Garre.     Beitr.  z.  klin.  Chir.  Bd.  9,  1892. 


CHAPTER  VII 

LIPOMATA 

Lipomata  are  tumors,  the  structure  of  which,  closely  resembles  that 
of  normal  fatty  tissue.  They  consist  of  a  smooth,  yellowish,  more  or 
less  lohulated  mass;  appear  singly  or  in  numhers;  are  symmetrically 
postured  in  some  cases ;  and  are  essentially  benign  in  character. 
When  removed  they  show  no  tendency  to  return.  In  rare  instances 
lipomata  are  congenital,  but  most  often  develop  between  the  ages  of 
thirty  and  fifty.     They  appear  in  women  more  frequently  than  in  men. 

With  the  exception  of  the  small,  symmetrical,  multiple  form  of 
lipoma,  which  develops  in  a  few  months,  the  growth  of  these  tumors 
is  very  gradual.  The  tumor  growth  originates  in  large  cells,  which  in 
early  life  are  free  from  fat,  but  later  become  the  site  of  fatty  deposits 
and  are  ultimately  converted  into  fat  cells.  These  fat  cells  are  usually 
larger  than  those  contained  in  normal  fatty  tissue.  Masses  of  fat 
cells  are  grouped  together  by  a  fine  capillary  network  in  the  form  of 
grape  clusters.  The  blood  supply  is  derived  from  a  large  vessel  trunk 
which  sends  out  small  branches  to  various  groups  of  cells.  The  blood 
vessels  are  arranged  in  a  manner  similar  to  the  stem  and  small 
branches  of  a  grape  cluster.  In  the  lipomata  the  lobules  of  fat  are,  how- 
ever, not  —  as  in  normal  fatty  tissue  —  loosely  separated  and  clearly 
visible,  but  connected  by  connective  tissue  trabeculae,  forming  large 
lohules  and  projections.  The  surface  of  the  tumor  is  covered  with  a 
thin  connective  tissue  capsule,  which  projects  into  the  interior  of  the 
growth,  subdividing  it  into  compartments  of  various  dimensions.  The 
rare  form  of  non-lobulated  lipoma,  on  section,  shows  fine  connective 
tissue  trabeculae  derived  from  the  capsule. 

The  tumor  capsule  is  loosely  attached  to  its  environment,  unless  the 
growth  has  been  subjected  to  irritation  (such  as  friction  of  clothing, 
posture,  pressure  of  body,  etc.),  when  the  capsule  thickens  and 
becomes  firmly  attached  to  the  superimposed  skin  or  to  the  deeper 
tissues;  this  of  course  makes  extirpation  of  the  tumor  less  easily 
accomplished. 

1134 


LIPOMATA  1135 

It  is  worthy  of  note  that  lipomata  do  not  decrease  in  size  when  the 
'  host  is  emaciated. 

The  hlood  supply  of  lipomata  is  meager  and  consists  (even  in  large 
growths)  of  vessels  that  extend  into  the  mass  in  the  connective  tissue 
trabeculae. 

Usually  the  tumor  mass  is  soft,  but  when  there  is  a  considerable 
deposit  of  connective  tissue  it  may  be  hard  {hard  or  soft  lipomata). 
Tumors  in  which  connective  tissue  proliferation  predominates  are 
designated  as  fihroliponiata;  when  fatty  tissue  is  in  great  preponder- 
ance the  term  lipofibromata  is  emploj'ed.  The  term  angiolipomata  is 
applied  to  tumors  rich  in  blood  vessels.  T\imors  containing  mucous 
membrane  elements  are  called  myxolipomata,  those  with  smooth  muscle 
fibers  (chiefly  found  in  the  kidney)  are  termed  myolij)omata. 

Calcification  and  the  rare  ossification  of  the  trabeculae,  edema  and 
softening  of  the  fatty  tissue  into  an  oily  mass  (oil  cysts)  occur  in  very 
large  lipomata,  which  also  at  times  undergo  nutritional  disturhances 
leading  to  necrosis,  together  with  ulceration  of  the  skin,  erosion  of  the 
blood  vessels,  and  putrefaction. 

The  origin  of  lipomata  would  seem  to  be  ascribable  to  displaced 
germinal  tissue,  especially  when  they  appear  as  heteroplastic  tumors 
in  situations  normally  devoid  of  fatty  tissue,  or  when  they  are  con- 
genital and  make  their  appearance  over  clefts  in  the  skull  and  spine 
(encephalocele,  spina  bifida  occulta).  The  influence  of  heredity  has 
been  observed  only  in  rare  instances  (Blaschko^).  The  occurrence  of 
symmetrical,  multiple  lipoma  has  been  ascribed  to  trophoneurotic  influ- 
ences by  Grosch,^  a  view  supported  by  Kiittnitz^  and  by  Payr.* 
Grosch-  suggests  that,  as  lipomata  usually  appear  in  situations  poorly 
supplied  with  grandular  structures,  development  of  these  tumors  is 
favored  b}'  a  lessening  in  the  rate  of  absorption  of  the  products  of  fat 
metabolism.  Lj'on^  thinks  that  internal  secretions  may  be  responsible 
for  the  multiple  form  of  lipomata.  The  effect  of  a  single  traumatism, 
as  the  causative  factor  is  claimed,  but  is  not  proved.  On  the  other 
hand,  prolonged  irritation,  such  as  the  pressure  of  weights  carried  in 
a  certain  position  (peddlers,  post  bearers,  etc.),  would  seem  to  favor 
the  development  of  lipoma. 

Lipomata  are  most  often  located  in  the  subcutaneous  cellular  tissue 
of  the  shoulders  and.  hach,  less  often  in  the  breast,  the  neck,  the  but- 
tocks, and  rarely  on  the  face,  scalp,  scrotum  or  vulva  (StolP). 

Subcutaneous  lipomata  may  be  small  flat  tumors,  or  may  reach  the 
size  of  the  adult  hand  or  larger.     Thev  elevate  the  skin  in  dome  form 


1136 


TUMORS 


or,  as  their  size  increases,  sag  into  a  pendulous  mass  with  either  a 
broad  base  or  a  slender  pedicle  {lipoma  pendulum) .  When  great  size 
is  attained,  circulatory  stasis  may  cause  the  skin  over  the  tumor  to 
become  edematous. 

The  superimposed  skin  is  normal  in  appearance  and  movable,  and 
may  be  lifted  from  the  tumor  in  folds,  which  vary  in  size  according  to 
the  thickness  of  the  subcutaneous  fat.  When  the  skin  is  made  tense 
over  the  mass,  shallow  grooves  corresponding  to  the  connective  tissue 
trabeculae  may  be  made  out.  These  are  especially  noticeable  when 
the  skin  is  thinned  out  and  adherent  to  the  tumor. 


Is^^-^-^/^' \|  |j-. 


"\^ 


Fig.  540. —  Section  of  a  Subcutaneous  Fibrot.ipo^ia  of  the  Gluteal  Region. 
The  skin   and  a  thin  layer  of  subcutaneous  fat  pass  over  the   surface  of  the 
encapsulated  tumor. 


Pain  occurs  in  connection  with  lipomata  when  they  make  pressure 
upon  sensory  nerves.  Multiple  symmetrical  lipomatosis,  being  asso- 
ciated with  changes  in  the  connective  tissue  of  nerves,  is  attended  with 
considerable  pain,  a  manifestation  which  led  Dercum^  to  regard  the 
condition  as  an  irregular  form  of  so-called  adiposis  dolorosa.  In  a 
general  way,  however,  lipomata  do  not  produce  marked  disturbances, 
except  when  their  location  interferes  with  function. 

Subfascial,  siib aponeurotic,  intermuscular,  and  periosteal  lipomata 
are  comparatively  rare  and  usually  appear  in  certain  situations. 

Subaponeurotic  lipomata  appear  upon  the  skull  beneath  the  occipito- 
frontalis  and  are  likely  to  be  more  or  less  firmly  attached  to  the  peri- 


LIPOMATA 


1137 


osteuin  of  the  frontal  region,  where  they  form  small  round  tumors! 
These  tumors  are  often  surrounded  by  a  ring  of  infiltrated  periosteum, 
causing  them  to  bear  some  resemblance  to  dermoid  cysts,  which 
frequently  lie  in  a  bony  depression. 

In  the  palm  of  the  hand  lipomata  are  usually  situated  beneath  the 
palmar  fascia,  whence  they  extend  between  the  metacarpal  bones  and 
appear  upon  the  dorsum.     Small  lipomata  are  occasionally  seen  upon 

the  flexor  aspect  of  the 
fingers,  where  the}'  are 
either  subcutaneous  or  are 
located  close  to  the  bone. 

Subfascial  lipomata  are 
also  found  in  the  neck,  the 
back,  and  in  the  abdominal 
wall.  They  often  send  out 
projections  between  the 
muscles. 

Inicrmuscular  lipomata 
are  found  upon  the  back, 
in  the  thorax  (under  the 
pectoralis  major),  in  the 
extremities  and  in  the  ab- 
dominal wall.  A  number 
of  the  lipomata  of  the  face 
develop  between  the 
muscles  in  the  fatty  cheek 
pad,  though  others  arise 
from  the  mucosa,  and  at 
times  a  tumor  of  this  sort  is 
found  in  the  tongue. 

Periosteal  lipomata  are 
rare.  They  are  more  or 
less  widely  connected  with 
the  surfaces  of  the  bones  (skull  and  long  tubular  bones)  and  may 
cause  pressure  atrophy  of  the  bony  tissue  (Schwarz  and  Chevier*). 
AVehrsig^  reports  a  case  of  lipoma  of  the  medullary  canal  of  the  fibula. 
Lipomata  of  the  abdominal  cavity  are  not  common.  The  lipomatous 
proliferation  of  the  omentum,  which  develops  in  connection  with  an 
old  irreducible  omentocele,  is  well  known.  At  times,  certain  of  the 
appendices  epiploicce  hypertrophj^  and  take  on  the  form  of  tumors, 


Fig.  541. —  DiFFrsE  Symmetrical  Lipoma. 


1138  •  TUMORS 

become  separated  from  the  ^t,  and  exist  as  free  bodies  in  the  abdom- 
inal cavity.  Small  submucous  lipomata  occasionally  develop  in  the 
stomach  wall.  Enormous  lipomata  develop  in  the  retroperitoneal 
tissue.  Extirpated  tumors  of  this  sort  have  been  known  to  weigh  from 
twenty  to  fifty  pounds.  Mesenteric  lipomata  are  situated  either  at 
the  root  or  at  the  site  of  the  intestinal  attachment.  Suhscroiis  lipo- 
mata, which  protrude  through  natural  openings  or  which  separate  the 
linea  alba,  are  covered  with  funnel  shaped  processes  of  peritoneum. 


Fig.  542. —  Subcutaneous  Lipoma  in  the  Eegion  of  the  Hip. 


Of  the  organs,  the  kidney  is  most  often  visited  by  lipomata;  they 
are  small  (size  of  a  walnut),  contain  unstriped  muscle  fibers,  and  are 
located  in  the  cortex  of  the  organ.  Other  organs,  such  as  the  lung, 
liver,  heart,  uterus,  mamma,  or  tonsil  may  be  the  site  of  a  lipoma, 
though  this  is  extremely'  rare.  Lipomata  have  been  found  attached  to 
the  yia,  at  the  base  of  the  brain. 

Lipoma  arlorescens  is  a  peculiar  form  of  fatty  tumor  developing 
from  the  joint  villi.     These  club  shaped  tumors,  found  in  large  num- 


LIPOMATA  1139 

bers  in  the  knee  joini,  were  first  described  by  Johann  Muller/°  and 
are  believed  to  be  the  result  of  frequently  repeated  chronic  inflamma- 
tory processes.  They  are  also  found  in  the  sheaths  of  tendons,  espe- 
cially in  those  of  the  hand  (Stiede^^). 

Lipomata  are  also  found  in  the  orhital  cavity,  the  vas,  the  tongue, 
and  in  the  retrot)iammarij  tissues. 

The  diagnosis  of  superficially  located  lipomata  is  not  attended  with 
especial  difficult}'.  The  location  of  the  tumor,  its  slow  growth,  sharp 
borders,  its  motility,  the  lohulatcd  arrangement,  and  the  indefinite 
sense  of  fluctuation  imparted  to  the  palpating  fingers,  should  make  the 
character  of  the  growth  clear.  Painful,  s^Tumetrieal  lipomata  should 
be  differentiated  from  fibromata  nervorum  by  the  smooth,  spindle  form 
of  the  latter.  Deeply  located  lipomata  are  rarely  diagnosticated  as 
such,  but  may  be  regarded  as  benign  tumors,  the  identity  of  which 
can  be  determined  only  after  extirpation.  In  doubtful  cases,  in  which 
cysts  (dermoids,  cchinococcus,  hygroma)  and  tuberculous  abscesses 
must  be  taken  into  account,  aspiration  is  of  great  assistance.  Lipoma 
of  the  forehead  is  differentiated  from  periosteal  gumma  by  the  motil- 
ity of  the  former.  Large,  hard  lipomata  of  the  abdominal  cavity  may 
resemble  fibromata  or  fibrosarcomata;  the  soft  form  may  be  mistaken 
for  encapsulated  tuberculous  abscesses.  Retromammary  lipomata  are 
differentiated  from  mammary  tu))wrs  with  great  difficulty,  as  are 
subparotid  tumors  from  those  situated  within  the  gland. 

Extirpation  of  a  lipoma  is  usually  easily  accomplished.  The  tumor 
capsule  is  exposed  and  the  mass  readily  peeled  out  of  the  surrounding 
tissues.  "When  the  tumor  is  adlierent  it  must  be  liberated  with  the 
knife.  When  the  growth  is  large  it  may  be  necessary  to  excise  a  sector 
of  the  thin  or  edematous  skin. 

Clinically,  circumscribed  lipoma  is  differentiated  from  the  so-called 
diffuse  form.  The  diffuse  form  may  be  congenital,  being  associated 
with  partial  giantism,  or  it  may  occur  as  multiple,  symmetrical 
growths,  which  make  their  appearance  in  middle  life.  The  latter  in- 
volve the  neck  and  throat  (the  so-called  "fat  neck"  of  Madelung^^), 
the  trunk,  and  also  appear  upon  the  extremities,  where  they  form 
oblique  and  transverse  thick  folds. 

The  diffuse  lipomata,  designated  by  Billroth^^  as  lipomatosis  region- 
aria,  are  characterized  by  the  appearance  upon  certain  portions  of  the 
body  of  restricted  increase  in  fatty  tissue,  not  in  genuine  tumor  forma- 
tion. This  process  bears  the  same  relationship  to  polj'sarcia  and 
obesity  that  pediculated  fibromatosis  bears  to  elephantiasis. 


1140  TUMORS 

The  subcutaneous  fat  is  chiefly  involved,  though  proliferation  may 
progress  between  the  planes  of  muscles. 

Extirpation  of  tissue  of  this  sort  is,  of  course,  incomplete.  It  is 
undertaken  for  the  relief  of  pressure,  especially  in  connection  with  the 
larynx  and  trachea  and  for  the  cosmetic  effect.  The  removal  of  the 
tissue  is  not  followed  b}"  recurrence. 

Healing  of  the  sutured  wound  is  often  delayed  by  the  prolonged 
discharge  of  fatty  fluid  secretion,  which  at  times  oozes  from  the  stitch 
holes. 

BIBLIOGRAPHY 

1.  Blaschko.     Virchow's  Arch.  Bd.  124,  1831. 

2.  Orosch.     Deutsch.  Zeitschr.  f.  Cliir.,  Bd.  26,  1887. 

3.  KuTTNiTZ.     Deutsch.  Zeitschr.  f.  Chir.,  Bd.  38,  1894. 

4.  Payr.     Wien  klin.  Woeh.,  1895,  with  lit. 

5.  Lyox.     Arch.  Int.  Med.,  1910,  vi. 

6.  Stoll.     Beitr.  z.  klin.  Chir.,  Bd.  8,  1892. 

7.  Decrum.     See  Payr  No.  4. 

8.  ScHWARz  et  Chevier.     Rev.  de  chir.  T.  33,  1906. 

9.  Wehrsig.     Zentrbl.  f.  Pathol.,  1910. 

10.  JoHANN  Mt'LLEK.     See  Stieda  Xo.  11. 

11.  Stieda.     Beitr.  z.  klin.  Chir.,  Bd.  16,  1896. 

12.  Madelung.     Arch.  f.  klin.  Chir.,  Bd.  37,  1888. 

13.  Billroth.     See  Payr  No,  4. 


I 


CHAPTER  VIII 
CHONDROMATA 

Tumors  consisting  of  cartilage  cells  are  called  choudromata.  Tumors 
of  this  nature  developing  in  situations  normally  devoid  of  cartilage 
are  called  enchondromata  (i.  e.,  heterogenous  chondromata),  those 
originating  in  normal  cartilage  are  called  ecchondromata.     Hyper- 


FiG.   543. —  Chondroma,  Showing   P.inon   Vessels  and  Bont  Arches. 

plastic  proliferation  of  cartilage  is  called  ccchondrosis,  though  a  sharp 
distinction  between  it  and  tumor  formation  is  not  always  possible. 

Cartilage  tumors  are  nodular,  soft  or  hard,  Muish  opalescent 
growths  resembling  normal  cartilage.  They  are  single  or  multiple 
and  may  be  very  numerous.     As  a  rule,  they  grow  slowly,  but  may 

1141 


1142 


TUMORS 


suddenly  rapidly  increase  in  size.     They  appear  early  in  life  and  are 
most  frequent  in  the  female  sex. 

Histologically,  the  structure  of  chondromata  differs  from  that  of 
normal  cartilage.  In  the  former  the  cells  are  oval,  round,  spindle  or 
star  shaped,  are  without  a  capsule,  and  are  irregularly  distributed. 
The  hasal  suhstance  consists  of  hyalin,  elastic  or  connective  tissue 
cartilage.  Fine  fibrillae  of  connective  tissue,  together  with  blood  ves- 
sels, permeate  the  growth  and  divide  it  into  irregular  nodules.  Chon- 
dromatous  tissue  frequentl}'  coexists  with  fibromatous,  myxomatous, 
osteomatous,  and  hemangiomatons  tissue  (fibrochondroma,  chondro- 
fibroma,  etc.).  At  times,  the  process  is  complicated  by  the  presence  of 
sarcoma  tissue  {chondro- 
sarcoma or,  when  bony 
tissue  is  present,  osteo- 
sarcoma). 

The  growth  of  chondro- 
mata is  at  times  expan- 
sive, at  others,  infiltrating 
in  character.  They  may, 
therefore,  be  either  teiiign 
or  rnalignant.  When  the 
tumor  is  surrounded  by  a 
layer  of  perichondrium- 
like  tissue,  it  simply  dis- 
places the  surrounding 
tissues ;  when,  however, 
this  is  absent,  as  it  is  in 
the  soft,  richly  cellular 
form  of  growth,  the  car- 
tilage cells  proliferate  into  the  spaces  between  the  contiguous  struc- 
tures, invade  the  veins  and  lymph  vessels  and  are  conveyed  into  the 
lungs  and  lymph  nodes. 

Of  the  changes  chondromata  undergo,  that  of  ossification  (ossifying 
chondroma)  is  the  most  common.  This  is  accomplished  by  the  exten- 
sion of  blood  vessels  into  the  tumor  mass  in  a  manner  similar  to  the 
normal  process.  In  this  way  an  entire  tumor  mass,  with  the  exception 
of  a  thin  outer  layer,  becomes  ossified  (cartilaginous  exostoses).  The 
most  important  change  is  the  appearance  of  sarcoma  tissue.  Only  too 
often  does  a  chondroma,  which  has  all  the  characteristics  of  a  benign 


Fig.  544. —  Chondroma  of  Phalanx. 


I 


CHONDROMATA  1143 

growth,  suddenly  increase  in  size,  invade  the  surrounding  tissues  and 
develop  metastases. 

The  meager  nutrition  of  chondromata  renders  them  exceedingly 
liable  to  regressive  changes.  These  consist  of  calcification  and  of 
softening;  in  the  latter  case  certain  sectors  become  colloid  (chondroma 
myxomatodes),  or  they  liquefy,  forming  fluid  cysts  {chondroma  cysti- 
cuni).     Pressure  ulceration  oi  the  skin  is  rare. 

Chondromata  are  most  often  located  in  the  osseous  system,  where 
they  make  their  appearance  in  early  life,  or  they  are  congenital.  As 
a  rule,  they  are  found  in  the  phalanges,  and  in  the  metacarpal  and  the 
metatarsal  hones,  where  they  are  single  or  multiple.  In  the  last  two 
situations  they  are  usually  nodular  in  form.  The  tumor  appears  more 
frequently  in  the  metaphyses  than  in  the  diapliyses  (Nasse^),  and 
originates  from  the  interior  of  the  bone  more  often  than  from  its  sur- 
face. Cortical  chondromata  destroy  the  bone  and  form  deep  hollows 
in  its  surface ;  the  centred  grow  outward  and  also  destroy  the  bone,  so 
that  they  are  covered  ovAj  by  a  thin  layer  of  normal  bone  or  peri- 
osteum. The  residual  bone  is  likely  to  contain  small  islands  of 
cartilage. 

In  the  long  tuhular  hones  the  metaphyses  are  most  often  the  seat  of 
both  cortical  and  intra-osseal  chondromata.  While  in  the  phalanges 
the  tumor  growth  is  attended  with  thickening  and  enlargement,  in  the 
long  tubular  bones  proliferation  gives  rise  to  nutritional  disturbances, 
which  cause  shortening  and  deformation,  and  produce  a  clinical  pic- 
ture bearing  some  resemblance  to  rachitis.  A  centrally  located  chon- 
droma may  be  unobserved  and  may  gradually  destroy  the  bone  so  that 
slight  trauma  produces  a  fracture  (spontaneous  fracture)  ;  the  subse- 
quent proliferation  of  tissue  resembles  excessive  callus  formation 
and  is  difficult  to  differentiate  from  it,  even  in  the  X-ray  plate.  Cystic 
softening  of  central,  mostly  fibromatous,  chondromata  when  trauma- 
tized leads  to  the  formation  of  extensive  multilocular  cysts,  the 
contents  of  which  consist  of  brownish  fluid  containing  blood  detritus 
and  cholesterin. 

Of  the  bones  of  the  trunk,  the  pelvis  and  scapula  are  most  often 
affected.  The  tumor  is  found  less  often  in  the  jaivs,  the  rihs  and  the 
hones  of  the  skull,  while  the  vertehra',  the  clavicle,  the  sternum  and 
the  hyoiel  hone  are  very  rarel}'  invaded.  Enchondromata  often  exist 
together  with  multiple  cartilaginous  exostoses  (Fig.  545). 

The  origin  of  enchondromata  of  the  osseous  system  is  the  outcome 
of  disturhances  in  the  skeletal  a^dage,  either  during  intra-  or  extras 


1144 


TUMORS 


uterine  life.  Just  how  this  happens  is  unknown.  It  is,  however, 
certain  that  these  tumors  spring  from  embryonic,  cartilaginous  tissue 
displaced  from  the  epiphyseal  zones  into  the  bone  marrow  of  the 
diaphyses    (Virchow-).     It  is  not  unlikely  that  a  number  of  these 


Fig.  545. —  Enchondromata  of  the  Upper  Metaphyses  of  the  Bones  op  Both 
Thighs,  Associated  with  Exostoses  of  the  Lower  Ends  of  the  Bones. 


tumora  originate  from  islands  of  cartilage  which  have  been  displaced 
from  their  normal  environment  during  an  attack  of  rachitis.  Failure 
of  ossification  may  be  explained  on  the  ground  of  defective  develop- 


CHONDROMATA 


1145 


went  of  Mood  vessels,  a  view  upheld  by  the  frequent  presence  of 
hemangiomata  in  these  cases  (v.  Recklinghausen^).  Displaced  islands 
of  cartilage  cells  may  remain  dormant  or  give  rise  to  tumor  formation. 
When  trauma  is  followed  by  the  development  of  tumor,  it  may  be 
regarded  as  its  exciting  cause.  Ribbert*  believes  that  the  germinal 
cells  concerned  in  the  formation  of  chondromata  originate  from  the 

proliferating  layer 
of  the  epiphyses, 
while  the  dormant 
cells  face  the  epi- 
physis and  are  not 
concerned  in  prolif- 
eration. 

Cartilagin  ous 
growths  also  appear 
in  portions  of  the 
osseous  system  nor- 
mally free  from  car- 
tilage, where  they 
develop  in  the  form 
of  enchondromata. 
These  are  also  de- 
rived from  displaced 
cartilage  cells.  Car- 
tilaginous tumors  of 
the  diaphragm  de- 
velop from  displaced 
portions  of  the  skele- 
tal anlage ;  those  of 
the  ovary  from  por- 
tions of  the  primary  vertebrae  ;  those  of  the  thyroid  and  salivary  glands 
and  neck  from  portions  of  the  cartilages  of  the  branchial  arches.  Tumors 
around  the  ear,  trachea  and  bronchi  develop  from  portions  of  the 
aural  anlage  and  from  tracheal  and  bronchial  cartilages  respectively. 
Pieces  of  cartilage  which  have  not  proliferated  are  sometimes  found 
in  the  skin  of  the  cheek  (auricular  appendages),  being  derived  from 
the  aural  anlage,  and  also  in  the  parotid  tonsil  and  in  the  side  of  the 
neck,  being  remnants  of  the  branchial  clefts.  Chondromata  of  the 
articular  capsule  of  the  knee  joint  were  first  observed  by  ReicheP  and 
later  described  by  Lexer.®    RiedeP  and  BibergilP  found  them  in  the 


Fig.  546. —  Cystic  Enchoxdroma  of  the  Upper 

Humerus. 
Xote  the  fine  bony  trabeculae  between  the  cysts. 


1146  TUMORS 

wrist  joint,  Lexer^  in  the  elbow  and  the  hip,  Hagemann^°  in  the 
shoulder,  and  W.  Miiller^^  in  one  of  the  tarsal  joints.  HonseP^ 
describes  enchondromata  of  muscles  {masseter  and  deltoid)  which,  like 
joint  chondromata,  are  probably  due  to  displaced  embryonic  cartilage. 

A  portion  of  the  cartilage  tumors  occurring  in  organs,  such  as  the 
salivary  gland,  the  mammae,  the  kidney,  the  uterus,  etc.,  are  of  a 
complicated  structure  and  belong  to  the  mixed  tumors.  The  rare 
multiple  growths  occurring  as  small,  hard  nodules  on  the  inner  side 
of  the  larynx,  in  the  trachea  and  in  the  cartilages  of  the  rihs,  arid  also 
in  the  form  of  flat  tumors  in  the  sumphysis  pubis  and  intervertebral 
cartilages,  are  classed  with  the  ecchondromata. 

The  diagnosis  of  chondromata  is  not  difficult.  It  is  based  .on  the 
nodular,  hard  feel  of  the  tumor,  the  absence  of  pain,  the  mobilitj'  of 
the  superimposed  skin,  the  location  of  the  masses  upon  the  hands  and 
feet  (where  several  tumors  are  usually  found)  and  the  presence  of 
multiple,  cartilaginous  exostoses  on  the  metaphyses  of  the  long  tubular 
bones.  Single,  small,  cortical  chondromata  resemble  exostoses ;  how- 
ever, the  X-ray  plate  clears  up  this  point. 

The  X-ray  is  also  very  useful  in  differentiating  central  chondromata 
of  the  metaphyses  of  the  long  bones  from  chronic  inflammatory  foci 
and  from  myelogenous  sarcomata.  Inflammatory  foci  are  character- 
ized by  thickened  corticalis  due  to  proliferated  bone  tissue,  while  the 
bone  covering  a  central  tumor  is  thinned.  Distinct  bony  trabeculae 
may  be  seen  between  the  nodules  or  the  lobulated  cysts  of  a  chondroma, 
while  a  myeloid  sarcoma  casts  a  shadow  of  uniform  density  (Fig.  546). 

Chondromata  of  the  soft  parts  may  be  recognized  by  their  nodular 
character,  their  slow  growth,  and  their  sharp  borders,  together  with 
the  location  in  which  they  are  found.  However,  tumors  of  this  sort 
are  not  readily  differentiated  from  mixed  tumors. 

Chondrosarcomata  present  a  picture  similar  in  every  regard  to  that 
of  chondroma,  but  they  grow  faster  than  the  latter. 

Extirpation  of  chondromata  is,  when  possible,  indicated  in  all  cases, 
on  the  ground  that  their  precise  character  cannot  be  determined  and 
that  they  often  become  malignant.  Single  tumors  must  be  promptly 
removed,  when  they  are  multiple ;  those  which  grow  quickly  or  inter- 
fere with  function  should  be  extirpated. 

"When  the  bone  is  not  largely  destro.yed  by  the  growth,  an  effort 
should  be  made  to  excise  it  without  sacrificing  the  unaffected  part  of 
the  former.  In  the  procedure  all  portions  of  the  tumor  must  be  care- 
fully scooped  out.    Large  bone  defects  may  be  plugged. 


CHONDROMATA  1147 

If  the  process  recurs,  resection  of  the  bone  is  indicated.  Resection 
ia  also  indicated  when  the  invaded  bone  is  extensively  destroyed. 
Ampuiation  is  permissible  when  the  lesion  involves  single  fingers  or 
iocs,  and  at  times  it  becomes  necessary  to  remove  an  entire  limb. 
Large  enehondromata  of  the  pelvis  are  often  inoperable. 

BIBLIOGRAPHY 

1.  Nasse.     Samml.  klin.  Yortr.  Xo.  124,  1895,  with  lit. 

2.  ViRCHOw.     Deutsch.   Kliuik.,   1864,   No.   9;   also  Monatsbeitr.   d.  Kgl, 

Berlin  Acad.  d.  Wiss,  Matthew  Klasse,  1875. 

3.  V.  Recklixghausex.     See  Xasse  Xo.  1. 

4.  RiBBERT.     Geschwiilstlehre,  Bonn,  1904. 

5.  Reichel.     Chir.  kong.  Verb.,  1900,  ii. 

6.  Lexer.     Arch.  f.  klin.  Chir.  Ixxxi,  ii,  1906. 

7.  RiEDEL.     Chir.  kong.  Verb.,  1903,  i. 

8.  BiBERGiLL.     Zeitsehr.  f.  Orth.  Chir.  xxxiii,  1913. 

9.  Lexer.     Deutsch.  Zeitsehr.  f.  Chir.,  Bd.  88,  1907. 

10.  Hageaiax-V.     Med.  Klinik,  1913. 

11.  W.  Mlller.     Arch.  f.  klin.  Chir.  Ixvi,  1902. 

12.  HoxsELL.     Beitr.  z.  klin.  Chir.  xxiii,  1899. 


CHAPTER  IX 


OSTEOMATA 


Osteomata  are  benign  tumors  composed  of  hone  tissue.  In  their 
development  they  conform  to  periosteal  and  to  cnchondral  formation 
and  consist  of  either  compact  {osteoma  durum  or  chondrum)  or 
spongy  bone  {osteoma  spongiosum) ,  or  they  contain  large  spaces  filled 
with  bone  marrow  {osteoma  medullosum) .  Dependent  upon  the 
origin  of  the  tumor  tissue,  the  growth  is  covered  with  either  periosteum, 
or  cartilage  {periosteal  or 
fibrous  and  chondral  or 
cartilaginous  osteoma) . 

In  no  class  of  tumors  is 
the  distinction  between 
hyperplastic  proliferation 
and  new  growth  so  poorly 
defined  as  in  osteoma 
This  is  in  a  measure  due 
to  the  fact  that  bone 
reacts  readily  to  inflam- 
mations of  all  kinds,  and 
to  traumatic  irritation  in 
the  form  of  circumscribed 
and  consequently  tumor- 
like proliferation  {inflam- 
matory and  traumatie 
exostoses).      Again,    the 

development  of  many  kinds  of  tumors  is  attended  with  secondary 
ossification  of  degenerated  or  calcified  sections,  without  the  existence 
of  a  genetic  accord  w'ith  osteoma.  The  latter  exists  only  in  ossified 
fibromata  and  chondromata,  the  tissue  structure  of  which  is  derived 
from  the  osseous  system  (fibroma,  osteoma  ossificans).  In  addition  to 
this,  certain  hyperostoses  of  uncertain  genetic  origin,  such  as  the 
osteitis  deformans  of  Paget,  and  the  fibrosa  of  v.  Recklinghausen,  and 

1148 


Fig.  547 


Osteoma. 


OSTEOMATA 


1149 


the  leontiasis  ossea  of  Virchow,  may  proliferate  in  the  form  of  tumors, 
and  muscles  may  be  the  site  of  bony  formations  that  bear  considerable 
resemblance  to  tumors. 

Osteomata  are,  of  course,  chiefly  located  in  the  skeleton,  where  they 
appear  most  often  in  the  form  of  exostoses  which  emanate  from  the 
surface  of  the  hone,  though  they  may  originate  from  the  interior  in 
the  form  of  endosioses. 

Cartilaginous  exostoses  are  more  common  than  those  of  connective 
tissue  origin.  They  are  composed  of  either  spongy  or  compact  tissue 
and  may  be  single  or  m,uUiple,  and,  at  times,  are 
very  numerous.  Tumors  of  this  sort  are  congeni- 
tal, or  inherited,  or  appear  early  in  life.  They 
groiv  slowly  and  often  reach  the  size  of  an  adult 
fist,  forming  hard,  nodular  masses  attached  to  the 
bone  by  broad  or  narrow  pedicles.  As  a  rule,  they 
do  not  produce  disturbances  until  they  make  pres- 
sure upon  contiguous  nerves,  when  they  cause 
pain  or  their  situation  causes  interferences  with 
function.  When  a  certain  size  is  reached  sym- 
metrical growth  ceases,  but  a  moderate,  slow  de- 
gree of  development  extends  from  the  lateral 
aspect  of  the  tumor. 

Cartilaginous  exostoses  are  frequently  found  in 
the  zones  of  growth  of  the  long  tubular  bones  and 
their  metaphyses  and  at  times  extend  into  a  joint 
cavity.  Exostoses  developing  in  early  life,  when 
bone  growth  is  active,  are  very  likely  to  be 
engulfed  by  the  diaphysis.  At  times,  they  cause 
no  shortening  and  bending  of  the  bone ;  at  others, 
they  are  responsible  for  congenital  defects.  Car- 
tilaginous exostoses  are  also  found  on  the  ribs,  the  clavicle,  the  pelvis, 
the  scapula,  and,  occasionall}',  on  the  fingers  and  the  toes.  As  a  matter 
of  fact,  they  are  likely  to  develop  in  anjj  part  of  the  skeleton  where 
cartilage  originally  existed,  and  they  are  especially  frequent  in  the 
region  of  the  cartilaginous  epiphyses.  In  the  pelvis  the  lesion  is  often 
seated  in  the  epiphyseal  cartilages  and  the  crest  of  the  ilium,  and  in  the 
scapula  they  are  usually  located  on  its  inner  surface  and  at  the  outer 
edge,  where  they  interfere  with  the  function  of  the  arm. 

Multiple  cartilaginous  exostoses  are  likely  to  present  a  confusing 
clinical  picture.     They  are  often  associated  with  multiple  chondro- 


FiG.  548. —  Exostosis 
OF  THE  Femur. 


1150 


TUMORS 


mata,  especially  in  the  fingers  and  hands  and,  not  rareh^,  with  many 
anomalous  growths.  However,  strange  to  say,  they  do  not  often 
become  sarcomatous  (Chiari^). 

The   origin   of  cartilaginous   exostoses   is  generally  attributed   to 
errors  in  the  skeletal  anlage  and  the  later  processes  concerned  in 


Fig.  549. —  Multiple  Cartilaginous  Exostoses  of  the  Metaphysis  of  the 
Femur  and  Tibia,  with  a  Chondroma  of  the  Upper  Metaphysis  of  the 
Fibula  on  the  Eight  Side. 


osseous  development  (Virchow^) .  This  view  is  supported  by  the  fre- 
quent multiplicity  of  the  lesion,  its  not  infrequent  hereditary  char- 
acter and  the  coexistence  of  other  manifestations  of  faulty 
cartilaginous    development     (chondromata)     genetically    similar    in 


OSTEOMATA 


1151 


I 


origin,  its  fre(iuent  preseuee  in  sx'veral  members  of  the  same  family, 
and  also  by  the  small  islands  of  cartilage  often  found  in  the  region  of 
an  exostosis  (Chiari*), 

Exostosis  hursata,  a  special  form  of  exostosis,  is  at  times  located  at 
the  lower  epiphijsis  of  the  femur  and  is  furnished  with  a  separate, 
hood  shaped  capsule.  This  capsule  lies  in  contact  with  the  edge  of  the 
outer  cartilaginous  layer  of  the  nodular  exostosis  and  is  filled  with 
liquid  resembling  synovial  fluid.  The  bursa  owes  its  development  to 
external  irritation  and  liquefying  of  connective  tissue  in  the  same  way 
as  obtains  over  the  bony  prominences  in  connection  with  club  foot. 
The  origin  of  these  adventitious  bursae,  especially  when  they  con- 
tain numerous  free  cartilaflinous  bodies,  is  not  clear.  V.  Rindfleisch^ 
suggests  that  the  process  represents  an  ecchondrosis  of  the  joint  cap- 
sule, 1.  e.,  a  portion  of  the  eap-ule  is 
protruded  and  ultimately  becomes 
separated.  Fehleisen*  adduces  some 
evidence  showing  that  they  originate 
from  the  fetal  anlage.  Riethus"'  at- 
tributes the  free  bodies  to  prolifera- 
tion of  the  hrjalin  cartilaginous 
covering  of  the  exostosis  and  insists 
that  the  bursae  are  secondarily  de- 
veloped. 

The  diagnosis  of  cartilaginous 
exo.stoses  is  based  on  their  location, 
their  slow  growth,  their  hardness, 
their  sharp  borders,  and  their  con- 
nection with  the  bone.  Multiple  cartilaginous  exostoses  are  not  read- 
ily mistaken.  They  may,  perhaps,  be  confused  with  periosteal  fibro- 
mata or  with  chondromata ;  however,  the  X-ray  should  make  distinc- 
tion easy  in  this  regard. 

The  treatment  consists  of  extirpation.     They  do  not  recur. 
Fibrous  exostoses  are  not  readily  differentiated  from  circumscribed 
proliferations,  which  have  not  anything  in  common  with  tumor  forma- 
tions. 

Inflammatory  and  traumatic  irritations  of  the  periosteum  are  often 
followed  by  rapidly  growing  bony  deposits.  Fractures  are  also  at 
times  followed  by  the  formation  of  tumor-like  processes  that  originate 
from  the  parostcal  connective  tissue  or  from  the  periosteum  and  extend 
between  the  contiguous  muscles  (callus  luxurians) .     Other  exostoses 


Fig.   -j-jO. —  Subungual  Exostosis. 


1152 


TUMORS 


develop  where  persistent  pressure  irritates  circumscribed  areas  of 
periosteum  {subungual  exostosis  of  the  great  toe,  exostosis  on  the 
inner  side  of  the  head  of  the  first  metatarsal  bone  in  hallux  valgus)  ; 
others  are  located  at  the  insertion  of  muscles  .and  tendons  and  consist 
of  simple  roughening  and  enlargement  of  the  bone. 

True  fibrous  exostoses,  of  which  the  majority  are  of  the  hard  variety, 
are  most  frequently  found  attached  to  the  vault  of  the  cra^iium,  the 


Fig.  551.— Ivory-like  Exostosis  or  Osteoma  of  Skull 
(from  MacCallum's  "  Text  Book  of  Pathology  ")• 


walls  of  the  cavities  of  the  face,  and  the  jaws.    They  are  also,  though 
rarely,  found  in  the  great  toe  (Fig.  550). 

In  the  skull,  the  frontal  and  parietal  bones  are  most  often  involved. 
In  this  situation,  single  or  multiple  exostoses  appear  in  the  form  of 
excrescences,  buttens,  horns,  etc.,  and  are  covered  with  a  thin  layer  of 
periosteum.  They  arise  from  the  inner  or  outer  layers  of  the 
corticalis,  or  from  both,  on  opposite  sides  (Fig.  551). 


i 


OSTEOMATA  1153 

ExosTOses  of  the  orbital  cavity  and  the  various  cavities  of  the  face 
originate  in  part  from  the  periosteum,  though  the  osteo^nata  of  the 
frontal  and  sphenoidal  sinuses  develop  from  fetal  cartilaginaus  rests 
of  the  ethmoid.  When  growths  of  this  nature  fill  the  cavity  in  which 
they  lie  they  are  called  encapsulated  bony  bodies;  when  separated 
from  their  attachments  by  inflammatory  or  nutritional  necrosis  they 
are  called  dead  osteomata.  As  they  gradually  increase  in  size  they 
rupture  through  the  contiguous  bon^y  walls,  as,  for  instance,  outward 
from  the  frontal  sinus  or  from  the  orbital  cavity  and  the  sphenoid 
cells  into  the  cranial  cavity. 

The  jaw  hones  are  the  scat  of  encapsulated  osteomata,  osteofibromata, 
nodular,  often  very  large  periosteal  exostoses  and  central  tumors 
emanating  from  normal  or  from  displaced  embryonic  teeth. 

Fibrous  exostoses,  like  those  derived  from  cartilage,  occur  mostly  in 
early  life. 

The  clinical  significance  of  the  growths  located  in  the  skull  lies  in 
their  invasion  of  the  cranial  cavity,  pressure  on  the  brain  and  bulb, 
obstruction  of  sinuses  and  foramina,  pressure  on  nerves  (trigeminus, 
optic,  etc.),  and  in  the  deformities  they  cause. 

The  diagnosis  is  based  on  the  slow,  painless,  circumscribed  growth 
of  the  tumor  and  the  gradual  symmetrical  obliteration  of  the  affected 
cavity.  At  first  the  process  simulates  sarcoma,  and  in  all  cases  com- 
plicating sinus  inflammations  may  give  rise  to  the  primary  disturbance 
(empyema  of  the  antrum  of  Highmore  and  the  frontal  sinus).  The 
deep  shadows  thrown  on  the  X-ray  plate  are  of  great  diagnostic  aid. 
The  bony  proliferation  of  leontiasis  ossea  is  not  sharply  outlined. 

The  treatment  consists  in  thorough  removal  of  the  growth.  Local 
recurrences  are  due  to  retained  fragments  of  the  growth. 

Genuine  endostoses  of  the  long  tubular  bones  are  rare  (Virchow^, 
Bennecke").  In  the  vault  of  the  skull  they  originate  in  the  diploe 
and  extend  in  .both  directions.  This  makes  their  differentiation  from 
exostoses  impossible  (v.  Bergmann").  The  endostoses  occasionally 
arising  in  spong}-  bones  originate  from  small  islands  of  displaced 
compact  bone  tissue  (Stieda^). 

Osteomata  of  the  soft  parts  also  present  difficulties  with  regard  to 
differentiation  of  tumor  growth  from  inflammatory  proliferation  of 
connective  tissue  with  secondary  ossification.  This  is  also  true  in 
regard  to  osteoma  of  the  skin,  the  small  nodular  deposits  in  the  frmital 
region,  the  flat  growthsi  in  the  dura,  the  circumscribed  tumors  in  the 


1154 


TUMORS 


limg,  and  those  of  the  inner  surface  of  the  trachea,  and  in  the  penis, 
all  of  which  originate  from  displaced  cartilaginous  rests. 

An  impoitaut  clinical  picture  is  presented  by  ossification  of  the 
muscles.  The  peculiarity  of  the  process  renders  it  permissible  to  dis- 
cuss it  in  this  connection,  although  it 
does  not  properly  belong  to  the  domain 
of  tumor  formation. 

The  process  progressively  attacks  a 
number  of  muscles — myositis  ossificans 
progressiva — or,  when  due  to  traumatic 
irritation  of  a  single  muscle,  may  ap- 
pear in  the  form  of  myositis  ossificans 
circumscripta. 

^Myositis  Ossificaxs  Pkogre?5iva  is 
a  multiple  progressive  ossification  of 
various  muscles.  In  some  instances  the 
process  tegins  in  the  periosteum  (Vir- 
chow^)  and  forms  exo.stoses  at  the  at- 
tachment of  the  muscles  to  the  bone  and 
extends  to  their  connective  tLssue  ten- 
dons and  fascia :  in  others  it  hegins  in 
the  muscles  (Zoge  v.  Manteufel,^'' 
Lexer^^)  and  progresses  in  both  direc- 
tions to  their  attachments. 

Histological  examinations  in  the 
early  stages  of  the  process  (Lexer^^) 
reveal  a  cellular  embryonic  tissue, 
which  infiltrates  and  proliferates  in  the 
connective  tissue  and  the  fibers  of  the 
muscles  (perimysium  externa  and  in- 
terna), and  converts  them  into  firm 
fibrous  tissue  or  into  the  periosteal  or 
endochondral  t^"pe  of  bone  tissue.     In 

the  very  early  stages  the  cellular  proliferation  bears  some  resemblance 
to  an  inflammatory  process  Tsmall  cell  infiltration),  which  has  some 
clinical  significance  but  does  not  clear  up  the  question  of  causation. 
The  proliferation  extends  from  the  perimysium  to  the  peritendineum 
and  leads  to  ossification  of  the  tendons  and  fasciae. 

The  disease  iLsually  appears  during  the  first  twenty  years  of  life. 
Krause  and  Trappe^^  exclude  from  the  clinical  classification  of  this 


Fig.  55: 


progressrve  ossifying 
Myositis. 


OSTEOMATA  1155 

form  of  the  disease  all  cases  occurring  after  twenty,  an  arbitrary  posi- 
tion not  supported  by  others  (Lexer").  It  most  often  attacks  the 
male  sex.     Heredity  is  not  proved. 

The  affliction  progresses  in  stages  and  usually  begins  in  the  muscles 
of  the  neck  and  hack.  Its  onset  and  each  exacerbation  is  sudden  and 
is  attended  with  fever,  a  moderate  degree  of  redness  of  the  skin,  and 
swelling  of  the  affected  muscles  or  groups  of  muscles.  As  the  pain 
and  tenderness  gradually  disappear,  the  muscles  become  progressively 
doughy,  hard  and  small.  The  process  may  continue  for  a  long  time 
in  this  stage  of  connective  tissue  induration.  In  most  cases,  however, 
it  gradually  goes  on  to  ossification.  The  proliferated  bony  tissue  is 
deposited  in  the  form  of  coral-like  scallops,  stalactites,  and  plates, 
which  follow  the  course  of  a  muscle  and  extend  to  contiguous  ones. 
The  muscles  soon  cease  to  function,  and  as  tJie  ossification  bridges 
joints  these  become  ankylosed  (often  in  a  faulty  position)  from  disuse. 

Variable  periods  of  time  occur  between  attacks,  and  additional  areas 
are  progressivel}-  invaded,  until  almost  the  entire  musculature  of  the 
trunk,  the  limbs,  and  finally  those  of  the  jaw  are  involved.  In  this 
way  the  patient  is  converted  into  an  immovable  mass.  Ultimately, 
interference  with  the  introduction  of  food  and  the  occurrence  of 
aspiration  pneumonitis  terminates  the  case. 

The  cause  of  the  disease  has  been  made  the  subject  of  much,  but 
fruitless,  discussion.  Its  name  is  based  on  its  early  clinical  manifes- 
tations, i.  e.,  those  of  inflammation.  It  is  certain  that  the  connective 
tissue  of  the  muscles  is  infiltrated  with  an  embryonic  cellular  prolifer- 
ation, which  possesses  the  capacity  of  converting  it  into  hard,  dense 
fibrous  tissue  and  bone,  believed  to  be  the  result  of  a  disturbance  of 
the  skeletal  anlage.  Stempel"  suggests  faulty  differentiation  of  the 
mesenchyme,  in  which  muscle  connective  tissue  acquires  the  capacity 
to  form  bone.  Both  of  these  conceptions  are  supported  by  the  simul- 
taneous presence  of  malformations  of  the  fingers  and  toes  (micro- 
dactylism, ankylosis  of  phalanges,  absence  of  terminal  phalanges  and 
muscles)  in  cases  of  this  sort  (Virchow").  However,  the  fact  that 
muscle  connective  tissue  is  capable  of  engendering  bone  under  other 
conditions  (see  below)  suggests  that  a  congenital  cause  is  not  always 
e.ssential  to  the  process. 

The  diagnosis  presents  difficulties  only  in  the  beginning  of  the 
disease,  when  it  may  be  mistaken  for  any  of  the  local  inflammatory 
conditions. 

Treatment  has  no  influence  on  the  course  of  the  affliction.     The 


1156  TUMORS 

operative  removal  of  especially  disturbing  bridges  of  bone  (at  the 
jaws  and  joints)  is  not  followed  by  protracted  relief.  TTie  interposi- 
tion by  Lexer^^  of  a  transplanted  fat  flap  into  the  hip  joints  of  the 
case  shown  in  Fig.  552  proved  only  transiently  helpful.  An  effort 
should  be  made  to  render  the  unfortunate  fate  of  the  afflicted  less 
distressing  by  attention  to  his  comfort. 

Myositis  Ossificans  Circumscripta  is  more  common  and  for- 
'  tunately  is  devoid  of  the  ghastly  progressive  character  of  the  affliction 
just  described.  It  occurs  when  a  muscle  is  subjected  to  persistent  trau- 
matic irritation  or  to  a  single  severe  trauma.  The  affected  muscle  at 
first  swells  and  then  undergoes  the  same  histological  changes  as  obtain 
in  the  progressive  form  of  the  process.  The  area  of  ossification  is 
deposited  in  the  form  of  plates  or  cords,  which  begin  in  the  body  of 
the  muscle  or  grow  into  it  from  the  bone. 

So-called  rider's  hone  in  the  adductor  and,  at  times,  in  pectineus 
and  gracilis  muscles  results  from  continued  impact  against  the  saddle; 
the  "manual  of  arms  hone"  found  in  the  pectoralis  major  and  deltoid 
of  infantrymen  is  attributed  to  the  pressure  of  the  rifle,  while  that  in 
the  hranchialis  anticus  occurs  in  acrobats  from  straining  at  apparatus. 
In  addition  to  this,  ossification  follows  trauma  to  various  muscles,  such 
as  the  masseter,  the  temporal,  and  those  of  the  ball  of  the  thumb  and 
abdomen,  etc.  The  origin  of  these  deposits  is  explained  on  the  ground 
of  an  especial  tendency  on  the  part  of  the  muscle  connective  tissue  to 
form  bone  when  injured.  Whether  the  muscle  ossification  coincident 
to  various  diseases  of  the  nervous  system  (tabes,  syringomyelia,  etc.) 
is  to  be  regarded  as  due  to  trophic  disturbances  of  the  connective  tissue, 
or  to  injury  of  the  muscles  contiguous  to  pathological  joints,  is  not  clear 
(neurotic  myositis  ossificans  of  Kiittner^^). 

The  form  of  ossifying  myositis  following  a  single  trauma  appears 
slowly  and  about  a  month  after  the  injury.  It  is  found  most  often  in 
the  hrachialis  anticus  and  quadriceps  femoris  muscles.  The  connective 
tissue  is  converted  into  bony  cords,  which  are  surrounded  by  blood  or 
lymph  cysts  (Rammstedt^*').  The  lesion  at  times  follows  severe  con- 
tusions,  dislocations,  and  fractures,  and  is  not  readily  differentiated 
from  callus  luxurians  of  the  soft  parts.  The  assumption  that  the  pro- 
cess is  due  to  avulsed  portions  of  periosteum  is  not  proved ;  it  may  be 
the  result  of  a  tendency  on  the  part  of  the  connective  tissue  of  the 
muscle  of  certain  individuals  to  beget  bony  tissue. 

The  symptom'^  vary  with  the  location  and  extent  of  the  bony  deposits. 


OSTEOMATA  1157 

Some  of  the  disturbances  are  due  to  pressure  upon  nerves  and  blood 
vessels. 

The  seat  of  the  lesion  at  a  point  frequently  subjected  to  trauma 
should  arouse  suspicion,  which  may  be  soon  verified  by  the  X-ray  plate. 

The  deposits  at  times  disappear  spontaneoush'  and  perhaps  are  as- 
sisted in  this  by  massage.  Aizner^'  reports  good  results  from  the 
injection  of  fihrolysin.  However,  prompt  extirpation  would  seem  to 
be  the  treatment  of  choice. 

BIBLIOGRAPHY 

1.  Chiari.     Pra.ffer  med.  Woch.,  1892,  No.  35. 

2.  ViRCHOw.     Deutsch.  Klinik,  1864. 

3.  v.  RiNDFLEiscH.     See  Fehleisen  No.  4. 

4.  Fehleisex.     Arch.  f.  klin.  Chir.,  Bd.  33,  1886. 

5.  RiETHUS.     Beitr.  z.  klin.  Chir.  Bd.  37,  1903. 

6.  Bennecke.     Zentrbl.  f.  Chir.,  1904. 

7.  V.  Bergmaxx.     Handb.  d.  prakt.  Chir.  3rd  Aufl.  Bd.  i. 

8.  Stieda.     Beitr.  z.  klin.  Chir.,"  Bd.  45,  1905. 

9.  ViRCHOW.     Verh.  d.  Berlin,  med.  Gesel.,  1894,  i  and  ii,  and  1900,  i. 

10.  ZoGE  V.  Maxteufel.     Chir.  Kong'.  Verh.,  1896,  i. 

11.  Lexer.     Arch.  f.  klin.  Chir.  Bd.  50,  1895. 

12.  Krause  und   Trappe.     Fortschr.   a.   d.   Gebiet.   d.   Rontgstrahl,   Bd.   ii, 

1907;    also  Bd.  14,  1909. 

13.  Lexer.     Allo-em.  Chir.  ii,  Stuttffarf,  1914. 

14.  Stempel.     Mitteil  a.  d.  Grenzgeb.,  Bd.  3,  1893. 

15.  KuTTXER.     Erg.  d.  Chir.  and  Orthop.,  Bd.  1,  1910,  with  lit. 

16.  Rammstedt.     See  Kiittner  No.  15. 

17.  Aizner.     Miineh.  med.  Woch.,  1909. 


CHAPTER  X 

ANGIOMATA 

The  term  angioma  is  applied  to  tumors  consisting  of  abnormally 
arranged,  tortuous  and  dilated  vessels,  and  should  be  restricted  to 
lesions  presenting  newly  formed  vessels,  and  vessels  the  walls  of  which 
have  undergone  proliferation.  Blood  vessel  angiomata  or  heman- 
giomata  are  differentiated  from  lymph  vessel  angiomata  and  lymph- 
angiomata. 

Hemangiomata. —  Hemangiomata  appear  in  three  forms :  Heman- 
gioma simplex,  cavernosum  and  racemosum. 

Hemangioma  Simplex. —  Hemangioma  simplex  is  also  called  telan- 
giectasis, though  neither  term  describes  the  lesion,  as  it  consists  not 
only  of  a  dilitation  of  the  termi7ial  vessels,  but  also  contains  newly 
formed  vessels.  A  section  of  a  recently  excised  tumor  of  this  nature 
reveals  at  its  edge  a  number  of  dark  red  lobules  filled  with  blood. 
These  lobules  are  held  together  by  connective  tissue  attached  to  the 
skin  and  extending  into  the  subcutaneous  fat,  the  fascia  and  the 
muscle.  Frequently  the  growth  is  surrounded  by  a  firm  capsule  which 
is  adherent  to  the  vessels  entering  it. 

The  tumor  mass  consists  of  dilated,  interlacing  capillaries  and  small 
vessels,  the  w'alls  of  which  contain  flat  or  cuboid  endothelium  and  cir- 
cularly arranged  bundles  of  connective  tissue.  When  both  of  these 
structures  have  proliferated  (hyperplastic  angioma  simplex)  so  that 
the  walls  of  the  vessels  are  thickened  and  their  lumen  narrowed,  they 
are  difficult  to  differentiate  from  the  sweat  glands  which,  together 
with  numerous  sebaceous  glands,  are  always  present  in  the  tumor 
tissue.  Transformation  of  the  vessel  tubules  into  solid  cords  con- 
sisting of  endothelium  forms  a  transition  into  hemangio-endothelioma. 

Many  forms  of  the  connective  tissue  tumors  are  in  part  hemangio- 
matous  in  structure,  forming  angiolipomata,  angiofihromata,  angio- 
sarcomata,  etc.,  etc. 

The  extension  of  hemangioma  simplex  occurs  as  follows :  The 
growth  develops  by  a  process  of  budding  blood  vessels  that  extend 

1158 


ANGIOMATA 


1159 


I 


INTO  THE  SURROUNDING  TISSUES  AND,  BY  CONTINUAL  NEW  FORMATION, 
AND  LENGTHENING  AND  DILATATION  OF  CAPILLARIES,  ULTIMATELY  OCCUPY 

THE  ENTIRE  INVADED  AREA.  This  form  of  growth,  which  bears  some 
resemblance  to  the  infiltrating  character  of  malignant  disease,  may  de- 
stroy the  contiguous  tissues,  including  the  bone,  but  does  not  form 
metastases  nor  does  it,  when  encapsulated,  cause  destruction.  At  times 
the  tumor  grows  slowly,  at  others  rapidly,  and  often  remains  stationary 
for  considerable  periods  of  time.  However,  the  maximum  develop- 
ment is  reached  ni  a  relatively  short  period.   Secondary  infection  and 

its  attendant  hyperplasias 
may  cause  complete  in- 
volution of  the  process. 

The  origin-  of  heman- 
giomata  is  a:  cribable  to 
developmental  anomalies. 
According  to  Ribbert,^  a 
small  circumscrihrd  eapil- 
lary  area,  connected  with 
an  artery  and  a  vein,  is 
originally  isolated  from 
the  surrounding  capil- 
laries and  develops  inde- 
pendently;  a  view  sus- 
tained by  the  fact  that  the 
lesion  is  usually  situated 
in  the  zone  of  fetal  clefts, 
i.  e.,  the  lips,  the  cheeks, 
the  eyelids,  and  the  root  of  the  nose  {fissural  angiomata)  and  is  often 
multiple  and  frequently  present  at  birth. 

Simple  angiomata  are  most  often  located  in  the  skin  and  siihcu- 
taneous  tissues.  Although  they  appear  in  all  parts  of  the  body,  two 
thirds  of  them  involve  the  skin  of  the  face. 

Cutaneous  angiomata  are  either  congenital  or  appear  in  the  first 
few  weeks  or  months  of  life,  in  the  form  of  large  or  small,  pale  or 
dark  red,  sacculated  blotches  or  beet  colored  elevations  of  the  skin. 
They  often  begin  as  small  as  a  flea  bite,  from  which  fine  radiating 
vessels  encroach  upon  the  surrounding  skin  (nevus  vasculosus,  port 
wine  mark)  (Fig.  554).  In  some  instances,  the  process  extends  ivith 
startling  rapidity,  covering  the  entire  face  in  less  than  one  year;  in 


Fig.  553. —  Simple  Hemangioma  of  the  Skin. 


1160 


TUMORS 


others,  growth  is  very  gradual.     The  neighboring  veins  are  often 
dilated. 

When  the  lesion  extends  to  the  deeper  tissues  it  assumes  the  form 
of  nodular,  polypoid  or  lohulated  masses,  covered  ^Yith  dark  red,  thin 
skin  which  may  present  the  characteristics  of  elephantiasis  {elephan- 
tiasis hemangiectasis) . 

Subcutaneous  heniungiomata  develop  later  than  do  the  cutaneous. 
During  the  early  stages  they  are  covered  by  normal  skin ;  later  this 
becomes  thinned  out  and  a  bluish  shimmer  is  apparent,  which  is  more 
manifest     when     the     child 
cries,  or  a  protrusion  may  be 
noticed  when  exertion  is  in- 
dulged in.    Finally  the  lesion 
extends  to  the  epidermis  and 
slowly    appears    as    red 
blotches  of  greater  or  less 
magnitude    and    becomes    a 
cutaneous  hamangioma. 

When  the  skin  and  sub- 
cutaneous tissues  are  in- 
volved, either  from  within 
or  without,  the  growth  ap- 
pears as  bluish  protrusions 
and  lobules  which,  especially 
at  the  lips,  eyelids,  and  nose, 
form  mulberrjj-lil'e,  darlc, 
bluish  red,  pediculated  or 
flap  shaped  masses.  This 
form  often  merges  into  the 
cavernous  angioma. 

On  the  lips  simple  heman- 
gioma may  produce  a  macrocheilia  similar  to  lymphangiomata.  The 
upper  lip,  which  is  more  often  affected  than  the  lower,  hangs  down 
over  the  mouth  in  the  form  of  an  irregular  bluish  fold ;  when  the 
lower  lip  is  iuA'olved  it  protrudes  like  a  snout.  The  tumor  is  increased 
in  size  by  lowering  the  head  and  by  the  circulatory  disturbances 
coincident  to  emotions,  such  as  anger,  fear,  etc. 

Angiomata  of  the  eyelids  may  be  primary  in  this  situation  or  they 
may  be  involved  b}'  extension  from  the  temporal  or  nasofrontal  re- 


FlG. 


554. —  Simple    Cutaneous    and 

CUTANEOUS    HeJIAXGIOMA. 


Sub- 


ANGIOMATA  1161 

gions.  They  are  dangerous  because  of  possible  invasion  of  the  orbital 
cavity. 

Simple  hemangiomaia  of  the  scalp,  which  comprise  about  one  third 
of  those  of  the  head,  are  usually  located  on  the  forehead,  at  the 
glahella,  the  inner  end  of  the  eyehrotv,  and  over  the  fontanelles. 

Inflammatory  processes,  hemorrhage,  and  involution  are  the  im- 
portant changes  occurring  in  the  course  of  skin  hemangiomata.  Both 
small  and  large  flat  hemangiomata  have  partially  and  entirely  disap- 
peared as  the  result  of  obliteration  of  their  blood  vessels.  This  is 
often  the  outcome  of  inflammatory  processes  which  occur  sequentially 
to  injury  of  the  thin,  \'nlnerable  skin,  and  subsequent  ulceration  and 
cicatrization.  Hemorrhages  are  infrequent  and  readily  controlled  by 
jiressure. 

Besides  those  found  in  the  skin  and  siibcutaneous  tissues  and  at  the 
mucocutaneous  junctions,  simple  hemangiomata  are  occasionally 
found  in  fatty  tissue  (especially  in  that  of  the  orbital  cavity),  in  the 
muscles,  in  the  vicinity  of  tendons  (WeiP),  in  the  mammae,  in  hone, 
in  the  hrain  and  spinal  card,  in  the  placenta,  and  in  the  parotid  gland. 

A  special  multiple  form  of  the  lesion  appears  as  small  (size  of  a  pea) 
blotches  and  warty  hemangiomata,  together  with  numerous  soft,  pig- 
mented warts  all  over  the  surface  of  the  body.  These  manifestations 
present  themselves  late  in  life  and  gradually  increase  in  size.  Ogawa' 
has  shown  that  they  were  due  to  elongation  and  dilatation  of  the  capil- 
laries. 

Hemangioma  Cavernostjm. —  In  structure  hemangioma  cavernosum, 
resembles  the  corpus  cavernosum  of  the  penis  and  consists  of  rectiform 
blood  spaces.  It  often  represents  an  advanced  stage  of  the  simple 
form  and  some  of  the  lesions  consist  in  part  of  a  similar  structure. 

Histologically  the  growth  consists  of  irregular  holloiv  spaces  filled 
with  blood.  These  spaces  are  inclosed  in  a  connective  tissue  netivark 
containing  elastic  fibres,  are  lined  with  endothelium,  and  communicate 
freely  with  one  another.  The  tumor  is  nourished  through  a  single 
artery,  while  the  blood  returns  through  several  enlarged  veins.  Throm- 
bosis of  the  blood  spaces  leads  to  insular  connective  tissue  changes  or 
to  calcification  and  the  formation  of  phleboliths,  and  at  times  single 
cavities  are  isolated  from  the  other  spaces  and  form  blood  cjfsts.  The 
lesion  is  completely  or  partially  encapsulated,  or  the  capsule  may  be 
absent  so  that  the  growth  merges  into  the  surrounding  tissues  (Fig. 
555).  In  accord  with  this  constructive  distinction,  the  tumor  growth 
is  varj-ingly  expansive  or  infiltrating ;  or  is  sloiv  or  intermittently 


1162 


TUMORS 


rapid.  Encapsulated  lesions  become  stationary  very  soon.  Spontan- 
eous involution  of  restricted  zones  following  thrombosis  is  not  uncom- 
mon, and  at  times  the  connective  tissue  becomes  ossified. 

The  frequent  congenital  and  multiple  character  of  this  form  of 
hemangioma,  as  in  the  simple  form,  suggests  that  an  unknown  develop- 
mental anomaly  is  responsible  for  the  process. 

The  skin  and  the  subcutaneous  cellular  tissues  are  also  most  fre- 
quently invaded  by  this  form  of  the  lesion  which,  in  the  majority  of 
instances,  is  located  in  the  cheeks,  the  eyelids,  the  lips  and  the  scalp. 
The  other  portions  of  the  body  are  less  often  affected.  As  a  rule, 
cavernous  hemangiomata  are  congenital  or  appear  in  the  first  few 
months  of  life,  though  they  may  develop  later,  when  trauma  would 
seem  to  have  a  causative  influence.  The  cutnaeous  form  appears  as 
dark  blue,  almost  black, 
wart-like  and  large 
nodular,  mulberry-like 
lobules  and  flaps  cov- 
ered with  delicate 
epidermis.  The  subcu- 
taneous form  is  char- 
acterized by  a  flat 
swelling  covered  with 
normal  or  irregularly 
blotched   telangiectatic 

skin    which  is  usually    -^^^'  ^^^- —  Cavernous  Hemangioma  of  the  Subcuta- 

'  .        '       '  NEOUS  Fat   (After  Extirpation). 

flecked  with  verrucous 

protrusions.     Both  forms  may  develop  into  elephantiasic  flaps   (eZc- 

phantiasis  cavernosa).     In  the  cheek,  the  lips,  and  the  eyelids  the 

new  growth  may  extend  to  the  musoca,  which  it  attenuates  and  elevates 

in  the  form  of  blue  nodules  and  lobulated  masses. 

On  the  face,  extension  of  the  lesion  takes  on  a  menacing  form.  From 
the  cheeks  the  mucosa  of  the  mouth  and  the  lips  and,  at  times,  the 
entire  side  of  the  face  and  half  the  scalp  are  progressively  invaded. 
From  the  scalp  the  process  permeates  the  spongy  meshes  of  the  cranial 
bones  and,  using  the  emissaries  of  Santorini  and  the  large  veins  as 
avenues  of  approach,  establishes  connection  with  the  great  sinuses. 
At  times  it  makes  pressure  on  the  nerves,  especially  the  branches  of 
the  trigeminus,  and  causes  severe  pain. 

Cavernous  tumors  of  the  orbit  often  displace  the  eyeball  and  may 
cause  it  to  undergo  pressure  changes. 


ANGIOMATA  1163 

Cavernoma  also  develops  in  the  tongue  and  in  the  muscles  (muscles 
of  the  calf,  rectus  abdominalis,  sternomastoid,  masseter).  Of  the 
organs,  the  liver  is  most  commonly  affected.  In  this  situation  the 
process  is  multiple  and  is  only  discovered  at  autopsy ;  however,  the 
tumors  become  very  large,  and  at  times  are  pediculated,  especially 
in  children,  when  they  may  be  susceptible  to  operative  relief.  Tumors 
of  this  sort  have  been  found  in  the  spleen,  the  spinal  cord,  the  brain 
(Krause*),  the  uterus  and  the  gut  (MacCallum"^). 

Hemorrhage  from  ruptured  nodules  is  likely  to  be  severe,  though 
it  is  readily  controlled  by  pressure  or  by  the  cautery. 

The  diagnosis  of  simple  and  cavernous  angiomata,  aside  from  their 
characteristic  appearance,  rests  on  the  fact  that  they  can  be  emptied 
by  pressure  and  reassume  their  previous  dimensions  when  the  pres- 
sure is  released.  Dependent  posture  also  causes  the  growths  to  en- 
large and  to  deepen  in  color,  while  elevation  of  the  affected  part  causes 
the  reverse.  When  hemangiomata  of  the  skull  are  emptied  by  pres- 
sure (which  is  easily  accomplished)  the  depressions  in  the  bone  pro- 
duced by  the  growth  are  readilj'  palpable.  Deeply  located  and  calcar- 
eous tumors  and  those  that  also  contain  fatty  tissue  in  abundance  are 
not  compressible.  When  the  tumor  is  connected  with  a  large  artery, 
pulsation  is  discernible.  These  signs  render  recognition  of  this  class 
of  tumor  comparativelj^  easy.  However,  as  the  growth  may  be  in  a 
transitional  stage,  finer  distinction,  as  to  the  exact  tissues  involved, 
is  not  always  possible.  In  characteristic  eases,  differentiation  from 
angioma  racemosum  and  phlebectasis  does  not  present  unsurmountable 
difficulties. 

The  treatment  includes  several  methods  of  procedure. 

Both  superficial  and  deeply  located  encapsulated  tumors  of  the 
extremities  may  be  excised  after  the  part  is  exsanguinated  by  means 
of  the  V.  Esmarch  bandage.  In  other  portions  of  the  body,  temporary 
control  of  the  blood  supply  may  be  accomplished  with  the  fingers  or  by 
the  use  of  ring  formed  apparatus.  When  the  growth  extends  into  the 
deeper  tissues  and  has  no  capsule,  its  removal  may  be  rapidly  com- 
pleted with  a  sharp  curette;  once  the  tumor  is  removed,  bleeding 
from  the  nutrient  vessels  is  readily  controlled  by  the  usual  methods. 

Extensive  tumors  of  the  face  are  not  susceptible  to  excisi&n.  This 
is  also  true  of  the  perforating  cavernous  form  found  on  the  sk^ill.  In 
children  it  is  best  to  employ  bloodless  methods  of  relief  when  possible. 

Superficial  nevi  are  readily  obliterated  by  a  single  application  of 
fuming  nitric  acid.    Its  use  is  followed  by  the  formation  of  a  crust 


1164 


TUMORS 


which  soon  exfoliates  and  leaves  a  delicate  scar.  During  the  applica- 
tion the  surrounding  healthy  skin  is  protected  with  suitably  fashioned 
plaster. 

Multiple  ignipuncture  is  of  use  in  the  treatment  of  elevated  nodular 
nevi,  but  in  subcutaneous  hemangiomata  it  affords  relief  only  after 
frequently  repeated  punctures.  The  measure  is  followed  by  unsightly 
scarring  and  by  extensive  loss  of  substance  and  therefore  is  not  de- 
sirable when  the  lesion  is  located  on  the  face,  especially  on  the  nose. 
When  the  eschar  is  thrown  off,  the  raw  surface  is  treated  aseptically, 
in  order  to  prevent  infec- 
tion, which  is  likely  to  ex- 
tend to  the  meninges. 

The  introduction  o  f 
Payr's**  magnesium  arroivs 
in  all  directions  into  sub- 
cutaneous hemangiomata 
through  small  incisions  in 
the  skin  is  designed  to  pro- 
duce coagulation  of  the 
blood  in  the  tumor  meshes, 
which  are  thus  occluded. 
The  method  is  of  value  in 
the  treatment  of  inoperable 
hemangiomata  of  the  scalp 
and  face. 

The  injection  of  chemi- 
cals is  also,  though  slowly, 
attended  with  shrinkage  of 
the  lesion.  For  the  pur- 
pose, 1  to  4  c.cm.  of  70  to 
80  per  cent  alcohol  or  one 

per  cent  zinc  chlorid  is  injected  at  first  into  the  edge  and  later  into 
the  center  of  the  growth  at  intervals  of  several  days.  Points  where 
the  skin  is  thin  should  be  avoided,  as  sloughing  and  menacing  bleeding 
are  likely  to  occur. 

Wyeth'  injects  boiling  water  into  the  tumor.  The  method  has  been 
followed  by  good  results.  Oxner*  uses  frozen  carhon  dioxid.  The 
snow  ( — 79 °C.)  is  applied  for  twenty  seconds  at  a  sitting. 

The  X-ray  has  been  effective  in  a  number  of  cases. 

Hemangioma   Racemosum. —  Cirsoid    anigoma    {cirsoid    aneurism, 


Pig.  5:j(i. —  CiusoiD  Axeukis^-m  of  the  Face. 


ANGIOMATA  1165 

angioma  arteriale  racemosum)  is  composed  of  thickened  symmetrical 

or  sacculated  dilatatiotis  of  elongated,  plexiform  and  tortuous  ves- 
sels of  an  arterial  zone.  The  main  trunks  and  branches,  together  with 
the  finer  subdivisions  and  capillaries,  are  dilated  and  the  vessels  of 
lesser  lumen  assume  the  character  of  the  larger.  The  afferent  large 
artery  is  usually  widelj^  dilated,  either  as  the  result  of  the  same 
process  occurring  in  its  zone  of  distribution,  or  because  of  the  addi- 
tional labor  of  supplying  it.  As  the  lesion  grows  the  veins,  which  com- 
municate freel}'^  with  the  arteries,  also  become  dilated  and  are  con- 
verted into  large  pulsating  cords.  Where  both  the  arteries  and  veins 
are  dilated,  the  term  phleharteriectasia  is  used. 

In  most  instances,  cirsoid  angiomata  develop  from  simple  congenital 
hemangiomata ;  they  also  occur  in  response  to  frequently  repeated  me- 
chanical irritation.  The  latter  cause  would  seem  operative  in  cases 
of  habitual  tugging  at  the  aural  lobule,  and  tumors  of  this  sort  have 
occurred  in  the  hands  of  oarsmen  (Lexer^).  Rotgans^"  reports  a  case 
in  which  the  lesion  followed  a  dog  bite  of  the  lower  lip.  Often  the 
cause  is  not  discoverable. 

No  doubt  congenital  anomalies  in  the  anlage  of  an  arterial  sector  are 
the  predisposing  causative  factor. 

The  scalp  and  the  face  are  most  often  affected,  the  extremities  less 
so.  Of  the  latter,  the  vessels  of  the  hand  and  forearm  are  most  fre- 
quently involved.  In  rare  instances  the  arteries  of  the  brain  have 
been  affected  (Stertzing,'^  Blank^-). 

The  lesion  presents  plainly  visible,  angleworms-like  cords  and  s)iarls, 
covered  by  more  or  less  adherent,  thin  cyanotic  skin.  On  the  face 
the  tumor  is  usually  covered  with  telangiectatic  skin  and  gradually 
merges  into  normal  surroundings.  When  the  vessels  reach  a  certain 
degree  of  dilatation,  pulsation,  which  is  synchronous  with  the  heart's 
action,  makes  its  appearance.  The  palpating  hand  elicits  thrill  and 
ausculation  reveals  a  loud  blowing  or  buzzing  bruit.  When  it  is  pos- 
sible to  obstruct  the  afferent  artery  by  pressure,  these  signs  disappear 
and  reappear  when  the  pressure  is  released.  In  tumors  situated  upon 
the  head  and  face  the  activity  of  the  collateral  circulation  does  not 
permit  of  circulatory  exclusion  in  this  manner.  When  the  measure 
succeeds,  a  perceptible  increase  in  the  tension  and  a  marked  slowing  in 
the  rate  of  the  pulse  may  be  noted. 

The  groivth  of  cirsoid  angiomata  is  at  first  rapid,  and  gradually 
diminishes,  though  acute  exacerbations  of  development  occur  at  all 


1166 


TUMORS 


times.     Dilatation  of   afferent   arteries  and  veins  occurs  when  the 
process  is  far  advanced. 

The  disturhances  provoked  by  plexiform  angiomata  consist  in  head- 
ache, insomnia  and  vertigo  (due  to  throbbing  and  buzzing  when  the 
tumor  is  located  on  the  scalp  and  face),  pain  and  loss  of  function  when 
the  lesion  makes  pressure  on  the  nerves  and  muscles.  Pressure  degen- 
eration of  the  shin,  ulceration,  hemorrhage  and  infection  are  menacing 
complications.  At  times  disturbances  of  the  circulation  lead  to  necro- 
sis of  the  terminal  portions  of  the  extremities  (fingers  and  toes). 

The  diagnosis  is  based  on  the 
palpable  characteristics  of  the 
tumor  and  its  undefined  edges. 
The  treatment  is  not  satisfac- 
tory. Even  the  best  method, 
that  of  total  extirpation,  to- 
gether with  ligature  of  the  af- 
ferent arteries,  has  its  limita- 
tions. Ligature  of  the  affected 
artery  alone  is  of  no  value ; 
indeed,  it  is  not  rarely  followed 
by  necrosis  of  distal  parts.  In 
cases  of  hemangioma  racc- 
mosum  of  the  scalp  Krause^^ 
elevates  a  flap  of  the  affected 
scalp,  allows  the  ves.sels  to  be- 
come thrombosed  and  later  com- 
pletes the  extirpation,  a  meas- 
ure the  writer  has  employed 
with  success. 

The  injection  of  chemicals  and 
the  additional  bloodless  efforts 
at  relief  discussed  in  connection  with  the  other  forms  of  hemangiomata 
have  not  proved  of  value;  on  the  contrary,  they  seem  to  involve  con 
siderable  danger  of  thrombosis  of  the  greatly  dilated  veins  and  the 
formation  of  emboli. 

Cauterization   involves   danger    of    ulceration   and    uncontrollable 
bleeding. 

.  When  tumors  situated  in  the  extremities  ulcerate,  become  infected 
and  bleed,  the  question  of  amputation  must  be  given  serious  consider 
ation. 


Fig.  557.-^  Racemose  Hemangioma  of  the 
Scalp  (von  Langenbeek's  collection). 


ANGIOMATA 


1167 


Lymphangiomata. —  Lymphangiomata  are  much  less  frequent  than 
hemangiomata ;  they  appear  in  three  main  forms,  between  which  there 
are  many  transitional  stages. 

Lymphangioma  Simplex. —  Lj-mphangioma  simplex  is  allied  to  the 
simple  form  of  hemangioma  and  consists  of  prolifcraiion  of  the  lijmph 
vessels  of  a  restricted  zone  of  the  skin  and  subcutaneous  tissues  in 
which  the  connective  tissue  lying  between  the  vessels  is  also  concerned. 
The  congenital  form  of  the  lesion,  which  appears  as  flat  or  slightly 
nodular  areas  of  thickening  in  the  skin  of  the  neck  and  face,  may  be 
classed  properly  with  tumors.     On  the  other  hand,  the  masses,  flaps, 

and  folds  of  elephantiasie 
skin  and  subcutaneous  tis- 
sues sequential  to  chronic 
inflammatory  processes, 
more  properly  called 
lymphangiectases,  are  due 
to  lymph  stasis,  thrombosis, 
and  inflammatory  connec- 
tive tissue  hj'perplasia  and 
should  be  separated  from 
the  true  lymphangiomata. 
It  is  probable  that  the  rare 
s o-c  ailed  lymphangioma 
tuberosum  cutaneum  multi- 
plex, which  consists  of 
minute  j-ellowish  brown 
nodules  extending  over  the 
entire  surface  of  the  body, 
also  belongs  to  the  lymph- 
angiectases. When  the  endothelial  cells  of  the  lymph  vessels 
proliferate  and  completely''  occlude  their  lumen,  a  new  growth  de- 
velops which  belongs  to  the  group  of  the  endothcliomata.  These  his- 
tological changes  result  in  the  formation  of  hypertrophic  lymphan- 
giomata, with  which  most  wn"iters  classify  pigmented  nevi,  lentigenes, 
freckles  (epithelides)  and  flesh]/  warts  (verrucae  carneae),  all  of  which 
are  composed  of  round  collections  or  cord-like  masses  of  proliferated 
endothelial  cells  of  the  lymphatic  vessels  lying  in  a  connective  tissue 
reticulum.  In  the  pigmented  nevi,  connective  tissue  proliferation  pre- 
dominates, though  some  of  the  tumor  mass  is  also  made  up  of  filaments 
of  the  nerves  of  the  skin. 


Fig.    558. —  Lymphangioma,    Showing    Lymph 
Spaces    (section   of  sweat  gland). 


1168 


TUMORS 


Lymphangioma  Cavernosum. —  Lymphangioma  cavernosum  is  the 
most  frequent  form  of  diffuse  (without  a  capsule)  lympJiangioma.  It 
is  congenital  in  origin  or  develops  from  a  congenital  focus  in  the  skin, 
the  subcutaneous  and  the  intermuscular  tissues.  Its  structure  is  not 
unlike  that  of  hemangioma  cavernosum;  it  consists  of  irregularly  dis- 
tended spaces,  which  communicate  wdth  one  another  and  are  filled  with 
lymph.  The  spaces  are  composed  of  connective  tissue  meshes,  which 
also  contain  smooth  muscle  and  elastic  fibres  aud  small  lymph  nodules 
lined  with  endothelium.  The  contiguous  normal  lymph  vessels  com- 
municate to  a  certain  extent  with  the  area  of  the  dilated  ones,  so  that 
pressure  on  the  tumor  diminishes  its  size,  though  it  immediately  reas- 
sumes  its  original  outline  when  the  pressure  is  released. 

Cavernous  lymphangiomata  occur 
most  frequently  in  the  cheeks,  the 
tongue,  the  lips,  at  the  corners  of  the 
eyelids  and  at  the  side  of  the  neck.  The 
tumor  appears  as  either  a  fiat  or  loose 
swelling  covered  by  normal,  immovable, 
at  times  yellowish  or  reddish  skin  and 
merges  gradually  into  the  surrounding 
tissues.  In  the  cheek .{niacrom alia)  it  is 
usually  soft  and  smooth.  In  the  neck  it 
is  likely  to  be  nodular,  in  the  lips  {macro- 
cheilia)  it  looks  like  a  sausage,  in  the 
concha  (Fig.  559)  it  is  lobulated,  and  in 
the  tongue  (macroglossia)  it  causes  an 
irregular,  sometimes  extensive  enlarge- 
ment.    In  the  face  and  neck  the  lesion 

often  contains  a  considerable  quantity  of  proliferated  connective 
tissue,  which  causes  it  to  form  flaps  and  nodules  of  extensive  size 
(elephantiasis  congenita  lymphangiectasis).  Encephaloceles  and  my- 
eloceles are  often  hidden  beneath  lymphangiomata  when  tbese  occur 
in  situations  where  the  former  are  commonly  located.  L^'mphangio- 
mas  of  mucous  membranes  are  occasionally  found  in  the  pharynx  and 
soft  palate,  w^here  they  appear  as  soft,  red  elevations.  When  a  pharyn- 
geal lesion  grows  intermitently  and  is  attended  with  fever  it  may  be 
mistaken  for  diphtheria,  especially  when  the  mucosa  is  covered  with 
coagulated  lymph  discharged  from  the  tumor  (Suckstorff^*). 

The  growth  of  the  tumor  is  slow  and  steady,  though  a  sudden  in- 
crease in  size  is  not  uncommon,  especially  in  the  face,  where  inflam- 


FiG.  559. —  Congenital  Ca- 
vernous Lymphangioma 
OF  THE  Ear. 


ANGIOMATA  1169 

matory  processes  extending  from  the  mucosa  give  rise  to  inflammatory 
swellings,  which  helong  to  the  clinical  picture  of  every  lymphangioma 
(TaveP^).  Cavernous  tissue  encroaches  upon  the  skin  and  sends  out 
conical  protrusions  that  penetrate  between  the  muscles,  the  deeper 
nerves,  and  blood  vessels,  often  encircling  and  separating  them.  In 
some  instances  the  bone  has  been  invaded  and  destroyed  (Katholicki/^ 
PaltautV"  Wrede^**). 

.  The  diagnosis  of  cavernous  lymphangioma  is  made  on  its  faint  out- 
line, soft  consistence,  the  indefinite  sense  of  fluctuation  it  imparts,  its 
compressibility,  the  immobilitj^  of  the  superimposed,  almost  normal, 
skin,  its  periodic  increase  in  size,  and  the  location  of  the  lesion. 

Cystic  Lymphangiomata. —  C^^tic  lymphangiomata,  in  contradis- 
distinction  to  the  cavernous  form,  are  encapsulated,  even  when  exten- 
sion into  neighboring  tissues  takes  place.  A  sharp  line  of  demarcation 
is  present,  except  w^hen  the  tumor  is  being  transformed  from  the  caver- 
nous to  the  cystic  form.  Growths  of  this  nature  are  composed  of 
simple  or  multiple  cysts,  varying  from  a  pinhcad  to  an  infant's  head  in 
size.  The  cysts  are  filled  with  a  serous  fluid  that  maj'  contain  blood 
(when  the  tumor  has  been  traumatized).  The  several  cyst  cavities 
communicate  with  one  another,  but  have  no  connection  with  surround- 
ing tissues  and,  therefore,  are  not  reducihle  hy  pressure.  The  cyst 
walls,  which  are  lined  by  endothelium,  are  composed  of  connective 
tissue,  often  arranged  in  the  form  of  cavernous  meshes. 

Cystic  lymphangiomata  are  usually  located  in  the  subcutaneous  and 
intermuscular  connective  tissue  of  the  neck,  where  they  appear  in  con- 
genital form  and  often  develop  into  large  tumors.  They  proliferate 
from  the  side  of  the  neck  beneath  the  sternomastoid  near  the  angle  of 
the  jaw,  or  from  the  supraclavicular  region,  and  extend  in  all  direc- 
tions. In  accord  with  the  quantity  of  fluid  they  contain,  they  are 
clastic  and  flivctuating,  covered  by  movable  or  tense  skin,  or  thej'  are 
soft  and  relaxed.  In  the  latter  instance  pressure  may  make  some  of  the 
loculi  of  the  tumor  more  manifest  and  thus  render  the  walls  interven- 
ing between  the  cysts  palpable.  As  a  rule,  the  tumor  is  freely  movable 
beneath  the  skin.  Cystic  lymphangiomata  of  the  neck  are  likely  to 
make  menacing  pressure  upon  the  air  passages,  the  esophagus,  and 
the  large  vessels,  especially  when  an  accidental  infectious  inflammation 
occurs  and  rapidly  increases  their  size. 

Tumors  of  this  nature  at  times  present  themselves  in  the  cheeks, 
the  axilla,  the  groin,  and  the  flexor  aspects  of  the  extremities.     They 


1170 


TUMORS 


also,  thoug-h  rarely,  are  found  over  the  sacrum  and  in  the  folds  of  the 
mesentery,  where  they  contain  chyle. 

The  diagnosis  is  not  difficult  when  the  tumor  is  situated  in  an  usual 
location.  However,  they  must  be  differentiated  from  hranchial  or 
blood  cysts  of  the  neck  and  from  echinococcus  and  lipoma  in  the 
cheek.  In  regions  richly  supplied  with  lymphatics,  lymph  varices  may 
produce  conditions  simulating  multiple  cystic  Ij^nphangioma.  Over 
the  sacrum,  dermoids  or  teratoid  tumors,  and  in  the  mesentery,  cysts 
of  various  origins  must  be  excluded. 

The  congeyiital  origin  of  lymph- 
angiomata  is  indicated  by  their 
coincident  association  with  other 
developmental  anomalies  (myelo- 
cele, encephalocele) .  As  a  rule,  the 
changes  in  the  lymph  channels  are 
attended  with  proliferation  of  the 
contiguous  connective  and  fatty 
tissues  and  of  the  smooth  muscle 
fibers  of  the  vessels  (Eibbert^''). 

Lymphangiomata  are  benign 
tumors.  Their  menace  lies  in  their 
tendency  to  extend  and  make  pres- 
sure upon  important  parts  and 
organs.  At  times  complicating  in- 
haust  the  host,  and  in  a  certain 
number  of  cases  are  responsible  for 
a  fatal  outcome. 

the  formation  of  flstulae  which  ex- 
flammations  lead  to  involution, 
though  they  may  also  give  rise  to 

Extirpation  of  encapsulated  cystic  tumors  is  comparatively  easy. 
When  the  superimposed  skin  is  adherent  it  is  removed  with  the  growth. 
Often  extirpation  of  the  tumor,  together  with  its  stump,  may  be  ac- 
complished without  injuring  the  walls  of  the  C}^ts.  In  the  procedure 
care  must  be  taken  to  avoid  important  nerves,  which  are  very  likely 
to  be  adherent  to  the  growth.  The  wound  should  be  carefully  sutured 
and  subsequently  subjected  to  mild  pressure,  with  the  view  of  obviat- 
ing the  occurrence  of  lymphatic  fistulae  and  lymphorrhea.  Nasse^° 
warns  ag^ainst  the  danger  of  infection  in  connection  with  free  incision 
and  tamponade  of  the  cysts. 


Fig.  560. —  Section  of  Large  Cavern- 
ous Lymphangioma  Eemoved  from 
Neck. 


ANGIOMATA  1171 

Simple  and  cavernous  lymphangiomata  are  not  amenable  to  radical 
extirpation,  nor  is  wedge  shaped  partial  resection  of  much  value.  In 
macroglossia  and  macrocheUm  the  latter  method  is  extensively  em- 
ploj'ed,  but  is  often  followed  by  the  formation  of  fistulae  and  by 
menacing  progressive  inflammati&n.  In  this  class  of  cases,  the  less 
radical  measures,  consisting  of  injections  of  alcohol,  tincture  of  iodin, 
and  one  per  cent  zijic  chlorid  may  be  used.  Cauterization  is  not  ef- 
fectual. Bockenheimer-^  advises  the  preliminary'  introduction  of  mag- 
nesium pastiles,  which  produce  thrombosis  and  may  be  followed  by 
comparatively  safe  extirpation,  a  view  not  shared  by  most  surgeons. 

BIBLIOGRAPHY 

1.  RiBBERT.     Virchow's  Areh.  cli,  1898. 

2.  Weil.     Beitr.  z.  klin.  Chir.  Ixxx^'iii,  1913. 

3.  Ogawa.     Virchow's  Arch,  clxxxix,  1907. 

4.  Krause.     Surg,  of  the  Brain,  Berlin. 

5.  MacCallum.     Text  Book  of  Patholosrv,  Phila.,  1916. 

6.  Patr.     Deutsch.  Zeitschr.  f.  Chir.,  Bd.  63,  1902. 

7.  Wyetii.     Anns,  of  Surgr.  xix. 

8.  OxxER.     Quoted  by  Sauerbrueh,  Zentrbl.  f.  Chir.,  1909. 

9.  Lexer.     All.s'em.  Chir.  ii,  S  uttgart,  1914. 

10.  RoTGAXS.     Hiklebrand'.s  Jabresber.,  1897. 

11.  Stertzixg.     Zentrbl.  f.  Path.,  1908. 

12.  Blaxk.     Miinch.  med.  Woch.,  1910. 

13.  Krause.     Quoted  Ijv  Clairmont,  Areh.  f.  klin.  Chir.,  Bd.  85,  1908. 

14.  SrcKSTORFF.     Beitr.  z.  klin.  Chir.  Bd.  27,  1900. 

15.  Ta-el.     Zentrbl.  f.  Cliir.,  1899. 

16.  Katholicki.     Chir.  Kong.  Verh.,  1903,  i. 

17.  Paltaup.     Verh.  d.  path.  Gesellsch.,  1907. 

18.  Wrede.     Beitr.  z.  klin.  Chir..  Bd.  73,  1911. 

19.  RiBBERT.     Virebow's  Areh.,  Bd.  151,  1898. 

20.  Nasse.     Arch.  f.  klin.  Chir.,  Bd.  38.  1889. 

21.  Bockexheimer.     Clinic  Surg,  iii.,  Rebman. 


CHAPTER  XI 


SAECOMATA 


The  term  sarcoma  is  applied  to  the  large  group  of  tumors  of  the 
connective  tissue  class  which,  in  contradistinction  to  those  consisting 
of  fully  developed  tissue  (fibromata,  chondromata,  osteomata),  are 
composed  of  undeveloped  embryonic  tissue.  Sarcomata  are  character- 
ized .b.y  their  extraordinary  cellular  proliferaiion,  which  predominates 
over  interstitial  growth.  In  this  regard  sarcomata  resemble  the  his- 
tological activities  coincident  to  the  development  of  embryonic  con- 
nective tissue,  and  the 
cellular 
that 
formati 
tion 


matory  processes 
(especially  in  the  infec- 
tious granulomata)  and 
in  the  repair  of 
wounds,  except  that  in 
sarcoma  the  cells  do  not 
complete  their  cycle  of 
development  and  never 
form  true  connective 
tissue.  The  loiv  gradr 
of  development  or  the 
defective  tissue  matur- 
ity, as  Borst^  calls  it, 
together    with    their 

great  proliferative  capacity,  determine  the  malignant  character  of 
sarcomata.  Among  connective  tissue  tumors,  sarcomata  occupy  the 
same  position  as  do  the  carcinomata  among  epithelial  new  growths, 
MacCallum^  says  "A  sarcoma  is  a  tumor  arising  from  connective  tissue 
and  retaining  most  of  the  general  characteristics  of  connective  tissue, 
but  endowed  with  the  new  power  of  invading  and  entirely  destroying   j 

1172  I 


Fig.  561. —  Fibrosarcoma. 


SARCOMATA 


1173 


adjacent  structures  and  of  forming  colonies  of  its  own  tissue  in  dis- 
tant organs." 

The  multiplicity  of  sarcomata  is  apparent  in  both  a  histological 
and  a  cliiiical  sense.  However,  these  do  not  carry  out  an  accord  with 
each  other.  The  clinical  picture  of  a  sarcoma  is  often  quite  at  vari- 
ence  with  its  histological  structure.  This  makes  a  cla,ssification  of 
sarcoma  a  difficult  matter.  However,  of  those  offered,  the  one  of 
Ribbert^  would  seem  the  most  acceptable.  He  distinguishes  between 
sarcomata  composed  of   (1)    cells  of  all  the  interstitial  tissues,    (2) 

cells  resembling  Ij-mph 
corpuscles,  (3)  mucoid 
tissues,  and  (4)  pigment 
cells. 

Certain  dominant 
characteristics  are  com- 
mon to  all  sarcomata, 
though  these  are  more 
marked  in  some  than  in 
others. 

Sarcomata   consist 
principally    of    cellular 
elements  of  varying  size 
and   form    which,    com- 
pared to  the  interstitial 
substance,    are    exceed- 
ingly  meager.  In  accord 
with   the  origin   of   the 
tumor  the  intercellular  tissue  is  fihrillar,  cartilaginous,  osseous,  or 
mucoid,  mixed  with  more  or  less  remnants  of  the  infiltrated  and  degen- 
erated tissues.     Next  among  the  constituents  of  the  tumor  come  the 

BLOOD  VESSELS  ;  these,  AS  IN  GRANULATION  TISSUE,  ARE  DEVELOPED  FROM 
NEWLY  FORMED  CAPILLARIES  AND  FORM  THE  FRAMEWORK  OF  THE  GROUPS 
AND  COLUMNS  OF  CELLS  PROLIFERATING  IN  THEIR  VICINITY.      The  walls  of 

these  newly  formed  vessels  are  so  thin  that  arteries  and  veins  cannot  be 
differentiated.  In  some  tumors,  the  endothelial  vessel  cells  rest  in  con- 
tact with  those  forming  the  tumors,  in  others  they  are  separated  by 
connective  tissue  fibers  called  tumor  stroma,  which  permeates  the 
growth  in  the  form  of  a  network  dividing  it  into  alveolar  spaces  filled 
with  cells  {alveolar  sarcoma). 
When  the  tumor  is  rich  in  hlood  vessels,  aside  from  those  in  imme- 


Fig.  562. —  Large  Spindle  Cell  Sarcoma. 


1174 


TUMORS 


®«^''.^fci»    ?.c»v*f 


?•♦ 


& 


diate  association  with  the  proliferating  cells,  it  presents  a  transitional 
stage  to  perithelwma',  in  which  proliferation  emanates  from  perivascu- 
lar endothelial  cells.  This  is  especially  true  when  the  columnar  cells 
surrounding  the  vessels  do  not  coalesce  with  one  another,  but  are 
separated  by  intercellular  stroma,  lymph  or  blood.  These  tumors  are 
called  angiosarcomata,  but  as  this  name  is  also  used  for  peritheliomata, 
the  term  telangiectaiic  and  cavernous  sarcomata,  suggested  by  Borst,* 
would  seem  to  be  better. 

The  growth  of  a  sarcoma  is,  as  a  rule,  at  first  expansive,  so  that  its 
separation  from  the  thin  capsule  furnished  by  the  invaded  tissue  is 
easily  accomplished.  Later,  as  the  tumor  increases  in  size,  it  infiltrates 
the  tissues  hy  prolifera- 
tion of  cells  and  cell 
columns.  In  this  process 
sarcoma  grows  hy  pro- 
liferation of  its  own  cells 
and  not  by  transforma- 
tion of  surrounding  ele- 
ments into  tumor  tissue. 
The  cell  proliferation 
which  takes  place  in  the 
contiguous  tissues  is  re- 
active in  character  and 
is  not  properlj'  regarded 
as  tumor  formation . 
The  infiltrated  tissue 
undergroes  pressure 
atrophy  or,  as  the  circu- 
lation is  interfered  with, 

may  undergo  necrosis,  in  which,  perhaps,  proteolytic  ferments  may 
take  part.  Bone  is  not  uncommonl}"  disintegrated  by  the  tumor  cells. 
Cartilage  succumbs  very  slowly. 

Regressive  changes  are  active  in  all  sarcomata;  they  consist  in 
fatty  and  parenchymatous  degeneration  of  the  cells,  necrosis  of  entire 
sectors,  hemorrhages  into  the  tumor  mass,  thrombosis  of  the  blood 
vessels,  hyalin  degeneration,  and  obliteration  of  the  vessels  and  their 
surroundings.  Degenerated  hollow  spaces  and  blood  cysts  impart  to 
a  sectioned  surface  a  variegated  appearance,  consisting  of  yellow 
glutinous,  and  bloody  areas.  Necrosis  of  the  invaded  sl'in  leads  to  deep 
ulcerations,  in  which  putrefaction  often  develops.    The  cells  of  sarco- 


-•   *   *    *.V*»*    * 


~t**.-&» 


Fig.  563. — -Eound  Cell  Sarcoma. 


SARCOMATA 


1175 


mata  at  times  undergo  fatty  degeneration  after  an  attack  of  erysipelas, 
and  a  similar  change  is  occasionally  produced  by  the  X-ray.  Unfor- 
tunately neither  of  these  possesses  therapeutic  value. 

The  malignancy  of  sarcomata  finds  expression  in  the  formation 
of  metastases.  This  is  less  marked  when  in  fibrosarcoma  the  tumor 
is  encapsulated,  and  is  especially  frequent  in  round  cell  sarcoma 
when  the  growth  is  characterized  b}'  cellular  infiltration.  Secondary 
nodules  develop  through  the  lymph  channels  and  in  the  lymph 
nodes;  however,  sarcomata  do  not,  as  a  rule,  spread  by  the  lymph- 


FiG.  564. —  EouxD  LELL  Sarcoma  of  the  Cheek. 


atics,  as  does  carcinoma.  More  often  its  extension  occurs  by  the 
Mood  passages,  the  tumor  cells  invading  the  walls  of  the  blood  vessels 
in  the  region  of  the  primary  growth.  Either  the  tumor  tissue  grows 
into  the  veins  or,  which  is  more  frequent,  small  clumps  of  cells  or 
single  cells  become  separated  from  the  tumor  mass  and  are  carried 
hy  fhe  circulation  into  the  lungs,  and  from  there  to  the  liver,  the 
spleen,  the  bone  marrow,  the  kidney,  and  other  parts,  tissues  and 
organs  of  the  body.  The  structure  of  a  metastasis  is  similar  to  that 
of  the  primary  growth,  but  it  usually  proliferates  more  rapidly. 
The  effect  of  sarcoma  on  the  hody  is  often  expressed  by  irregular 


1176 


TUMORS 


fever,  due  to  the  absorption  of  pyrogenous  substances  absorbed  from 
the  tumor  mass  (extravasation  of  blood,  products  of  disintegration) 
and  by  progressive  anemia,  which  always  arouses  suspicion  that  the 
process  has  become  generalized. 

Sarcoma  occurs  most  frequently  in  middle  life.     In  children  it  is 


Fig.  565.- 


MuLTiPLE  Sarcomata  of  the  Skin  in  a  Man  Forty  Years  of  Age 
(Small  Cell  Variety). 


not  uncommonly  congeniial.    It  often  attacks  persons  in  good  health. 
It  is  usually  single  at  first,  but  may  be  multiple  from  its  onset. 

The  cause  of  sarcoma  is  unknown.  The  'parasitic  theory  has  not 
been  proved.  The  theory  that  the  growth  is  the  outcome  of  develop- 
mental anomalies  finds  support  in  its  congenital  occurrence ;  the  pres- 
ence of  sarcoma  tissue  in  mixed  tumors  (teratoid)  which  are  surely 
due  to  anomalies  in  development ;  the  fact  that  the  tumor  develops 


SARCOMATA 


1177 


from  misplaced  adrenal  rests,  from  undescended  testicles,  and  from 
congenital  processes  such  as  nerve  fibromata  and  soft  warts ;  likewise, 
in  the  development  of  bone  and  cartilage  in  sarcomata  of  the  soft 
parts  and  the  occasional  occurrence  of  sarcoma  tissue  in  benign  con- 
nective  tissue  tumors.  However,  germinal  tissue  may  become  capable 
of  proliferation  and  tumor  formation,  not  alone  in  the  embryonic,  but 
also  in  later  life  in  the  course  of  the  growth  of  the  body  and  during 
inflammatory  and  regenerative  processes  (Ribbert^).  With  respect  to 
regenerative  processes,  this  is  exemplified  when  sarcoma  develops  at 
the  site  of  a  fracture  {callus  sarcoma).  Yet  it  is  not  infrequently 
difficult  to  decide  whether  the  sarcoma  developed  sequentially  to  the 
fracture,  or  whether  the  latter  occurred  at  the  site  of,  and  because  of, 
a  sarcoma. 

Connective  Tissue  Sarcomata. — Sarcomata  which  develop  from  any  of 
the  connective  tissues  of  the  body  contain  less  fibrillar}^  intermediary 

substance,  but  in 
other  regards  they 
imitate  the  struc- 
ture of  emhryonic 
connective  tissue 
and,  when  they 
contain  cartilage 
and  bone,  originate 
from  the  skeletal  tissues   {chondrosarcoma],  osteosarcoma). 

Connective  tissue  sarcomata  are  most  often  composed  of  spindle  cells 
(sarcoma  fusocellulare),  less  frequently,  of  round  cells  {sarcoma  globo- 
cellulare),  though  small  and  large  cells  with  many  transitional  forms 
may  be  present.  Besides  the  soft  medullary  forms,  which  are  tery 
malignant,  there  are  also  the  firm  less  malignant  varieties  containing 
a  relatively  large  proportion  of  interstitial  fibres.  The  appearance  of 
the  sectioned  tumor  varies  in  accord  with  its  vascularity,  its  growth, 
the  presence  of  blood  pigment,  the  occurrence  of  hemorrhages,  and 
the  establishment  of  regressive  changes.  At  times,  the  sectioned  sur- 
face is  grayish  red,  at  others,  dark  red,  and  it  may  be  mottled  by 
bloody  areas  or  exhibit  zones  of  cj^stic  degeneration. 

Spindle  Cell  Sarcomata. —  Spindle  cells  taper  at  either  end  and 
have  the  nuclei  situated  in  their  centers.  The  lai^e  cells  are  usually 
irregular,  round  or  fusiform  in  shape.  The  cells  are  often  arranged 
in  fasciculi.  TTie  intercelhdar  fibriUae  are  present  in  large  quantity 
in  fibrosarcomata,  which  are  ditferentiated  from  fibromata  by  their 


Fig. 


566. —  Macroscopic  Section  of  S^vkcoma  Removed 
FROM  THE  Thigh. 


1178 


TUMORS 


large  nuclei,  their  rich  protoplasm,  and  the  irregular  form  of  their 
cells.  As  a  rule,  spindle  cell  sarcomata  are  coarse,  firm,  hard  tumors, 
which  for  a  long  time  grow  by  expansion,  do  not  cause  severe  local 
disturbance,  and  do  not  metastasize  as  frequently  as  the  round  cell 
form. 

Round  Cell  Sarcomata. —  Round  cell  sarcomata  are  composed  of, 
either  round  cells  meager  in  protoplasm,  or  large  cells  rich  in  proto- 
plasm and  containing  vesicular  nuclei.  When  the  cells  lie  in  a  well 
developed  stroma  (alveolar  sarcoma),  the  structure  of  the  tumor 
hears  considerable  resernblance  to  carcinoma.  The  growth  of  round 
cell  sarcomata  is  essen- 
tially infiltrating  in 
character  and  the 
tumors  are  more  often 
soft  than  hard  in  con- 
sistence. 

Persistence  in  type  of 
cell  is  seen  more  often  in 
spindle  cell  sarcoma.  In 
others  a  certain  form  of 
cell  dominates  the  mix- 
ture of  other  forms. 
Irregular,  atypical,  mi- 
totic figures  and  multi- 
nuclear  cells,  the  proto- 
plasm of  which  is  not 
capable  of  division  are 
indicative  of  defective 
growth. 

Giant  Cell  Sarcomata. — ■  Giant  cells,  which  closely  resemble  osteo- 
clasts, are  found  associated  with  spindle  and  round  cells  in  connec- 
tive tissue  sarcomata,  especially  in  those  arising  in  the  osseous  system. 
Giant  cell  sarcomata,  composed  principally  of  spindle  cells,  often  orig- 
inate from  the  periosteum  of  the  jaws  (epulis)  or  from  the  marrow  of 
tubular  bones,  and  form  a  relatively  benign  group  of  sarcomata. 

The  clinical  picture  of  connective  tissue  sarcoma  conforms  to  the 
situation  of  the  growth  and  the  degree  of  malignancy  it  represents. 

Sarcomata  of  the  skin  appear  as  rapidly  growing,  round,  clearly 
defined  nodules  and  masses,  or  as  pedunculated  fungiform  and  nodular 
tumors  of  varying  consistence,  and  are  usually  (because  of  their  vascu- 


FiG.     567.— Giant    Cell    Sarcoma     (Epulis), 
Showing  Giant  and  Spindle  Cells. 


SARCOMATA 


1179 


larity)  bluish  red  in  color.  They  are  at  first  covered  by  epidermis, 
but  when  this  disintegrates,  become  encrusted,  show  a  tendency  to 
bleed  and  often  break  down  to  form  large,  deep,  craterlike  ulcers. 
Tumors  of  this  sort  often  originate  from  warts  and  papiUamata  and 
may  appear  in  multiple  form.  As  long  as  they  remain  small  and  do 
not  extend  to  the  deeper  tissues,  they  are  movable  with  the  skin. 
Rapid  growth  is  indicative  of  the  degree  of  malignancy  of  the  tumor ; 
the  absence  of  enlarged,  hard  lymph  nodes  (which  is  not  constant) 
differentiates  the  process  from  carcinoma,  although  the  nodular  or 

ulcerated  surface  is  not  unlike 
that  of  the  latter.  The  multiple 
form  of  skin  sarcoma  bears 
some  resemblance  to  mycosis 
fuiifj  aides. 

However,  mycosis  fungoides, 
described  by  Albert!"  (1835), 
has  certain  peculiarities  in  its 
course  and  symptoms.  It  is  more 
common  in  men  than  in  women, 
begins  between  the  ages  of  thirty 
and  fifty  and  extends  over  a 
decade  or  more.  Its  onset  is 
preceded  by  prodromata  of  long 
duration,  which  consist  of  severe 
iiching  of  the  skin  and  the  ap- 
pearance of  an  erythema  or 
vesicular  or  scaly  eczema  and 
nodular  or  flat  areas  of  infiltra- 
tion, all  of  which  come  and  go,  to 
be  finally'  succeeded  by  the  formation  of  tumors  in  the  mycotic  stage  of 
the  disease.  The  mycotic  tumors  appear  in  the  form  of  broad  or  fungi- 
form, flat  shaped  and  furrowed,  hard  or  soft  masses,  which  are  dark 
red  in  color,  are  often  covered  with  moisture  and  may  reach  the  size  of 
the  adult  fist.  The  masses  often  disintegrate  from  the  center  and,  before 
disappearing  entirely,  assume  a  semicircular  or  garland-like  appear- 
ance. Ultimately  the  process  presents  a  deep  putrid  ulcerated  surface. 
The  microscope  reveals  fine  vascular  connective  tissue  (Tilden', 
Unna').  The  contiguous  lymph  nodes  are  swollen  by  inflammatory 
thickening;  cachexia  develops  and  secondary  general  infection  occurs, 
a  sequence  of  events  often  followed  by  death.     Healiiig  is  rare.     The 


Fig.  568. 


EorxD  Cell  Sarcoma  of  the 
Skix. 


1180 


TUMORS 


nature  of  the  disease  is  unknown.  It  is  believed  to  belong  to  the 
granulomata.  The  treatmerit  consists  of  intensive  administration  of 
arsenic.  Large  growths  may  be  extirpated  and,  strange  to  say,  show 
no  tendency  to  recur  (Wolters^). 

In  the  suhcutmieous  tissues,  sarcomata  appear  in  the  form  of  round, 
nodular,  somewhat  lobulated  masses  which,  at  first,  are  sharply  de- 
fined against  the  surrounding  tissues,  but  soon  become  attached  to  the 
superimposed  skin,  which  they  cause  to  dis- 
integrate. They  not  rarely  arise  in  connection 
with  neurofibromata.  As  a  rule,  they  are  com- 
posed of  round  and  spindle  cells.  The  diagnosis 
is  based  on  their  rapid  growth,  which  differen- 
tiates them  from  the  more  slowly  developing 
fibromata;  however,  they  are  not  readily  sep- 
arated from  gummas.  The  latter  are  usually 
associated  with  other  evidence  of  lues. 

Sarcomata  of  mucous  membranes  are  usually 
attached  by  a  broad 
base  or  consist  of  in- 
definitely outlined 
areas  of  thickening 
of  varying  consist- 
ency. They  break 
down  and  ulcerate 
very  easily  and  are 
composed  of  round 
and,  at  times , 
spindle  cells.  These 
growths  originate  in 
the  submocosa, 
though  they  may 
also  spring  from  the 

intermuscular  or  subserous  tissues  and  are  found  in  the  stomach  and 
gut,  in  the  tongue  and  the  trachea.  They  are  less  common  than 
carcinomata  of  the  mucous  membranes,  though  they  present  a  similar 
clinical  picture. 

Intermuscular  sarcomata  are  usually  composed  of  giant  cells  and 
grow'  very  rapidly,  at  times  reaching  enormous  difnensions  and  fre- 
quently completely  surround  the  bone.  Their  recognition  is  difficult 
only  in  the  beginning,  when  they  bear  some  resemblance  to  muscle 


Fig.  569. 


Sarcoma  Surrounded  by  a  Collar  of  the 
Perforated  Skin. 


SARCOMATA 


1181 


gumma,  and,  in  the  later  stages,  it  may  be  difficult  to  determine 
whether  the  process  originated  from  the  bone  or  from  the  muscles.  In 
this  situation,  sarcomata  are  usually  of  the  soft,  very  malignant  type; 
though  the  less  menacing  hard,  fibrous,  and  more  or  less  encapsulated 
form  is  also  occasionally  found  in  this  location. 

Both  forms  originate  in  the  fascia  and 
sheaths  of  the  hlood  vessels. 

Connective  tissue  sarcomata  of  the  peri- 
ostcum  are,  at  times,  multiple  (Nasse^). 
Fibrosarcomata  composed  of  spindle  cells 
with  a  moderate  addition  of  giant  cells,  hard, 
broad  or  pedunculated  in  form,  are  often 
attached  to  the  alveolar  processes  of  the 
jaws.  These  tumors  grow  slowly,  are 
covered  with  mucous  membrane,  and  are 
known  by  the  name  of  epulis;  they  are  often 
difficult  to  differentiate  from  fibromata. 
Tumors  of  this  sort  are  also  found  at  the 
ends  of  the  long  tubular  hones.  In  the  dura, 
spindle  cell  sarcomata  form  a  part  of  the 
tumors  grouped  under  the  general  head  of 
fungus  dura  matus.  "When  connective  tissue 
sarcomata  originate  in  the  hone  marrow  they 
are  usually  rich  in  giant  cells  and  are  not 
particularly  malignant.  They  present  a 
clinical  picture  similar  to  that  of  myelo- 
genous sarcoma.     (P.  1185.) 

Sarcomata  of  the  flexor  tendon  sheaths  of 
the  fingers  are  not  very  malignant.  They 
are  nodular  and  encapsulated,  and  often 
yellowish  brown  in  color,  an  appearance  im- 

FiG.     570.     Soft,     Small,   parted  by   hemorrhages  produced   in    their 
Spindle  Cell  Sarcoma  of    -^  ^  o       i 

THE  Fascia  Lata.  substance  by  trauma. 

Sarcomata  originating  in  the  connective 

tissue  of  nerves  cause  fusiform,  nodular  areas  of  thickening  of  the 

nerve  trunks  or  are  attached  to  their  lateral  aspects.    They  grow  more 

rapidly  than  fibromata.    Pain  in  the  distribution  of  the  nerve  may  be 

elicited  by  manipulation  of  the  growth.     At  first,  the  tumors  of  this 

sort  are  encapsulated,  but  later  extend  to  the  surrounding  tissues. 

Occasionallv  a  nerve  fibroma  becomes  sarcomatous. 


i 


1182 


TUMORS 


Retroperitoneal  sarcomata  of  this  group  arise  from  the  posterior  ab- 
dominal wall  and  in  the  mesentery,  and  reach  a  very  large  size.  They 
are  usually  hard  and  nodular  and  differ  clinically  from  fibromata  only 
in  their  rapid  extension. 

Connective  tissue  sarcomata  of  organs  (mamma,  thyroid  gland, 
testicle,  parotid  gland,  kidney,  uterus)  soon  destroy  the  parenchyma ; 


Fig.  571. —  Sarcoma  of  the  Mammary  Gland  (Haynes). 


those  of  the  serous  memhranes  (pleura,  peritoneum),  like  those  of 
joint  capsules,  are  rarely  primary.  Primar}^  sarcomata  of  lymph 
nodes,  aside  from  lymphosarcomata,  are  also  very  rare. 

The  diagnosis  of  the  presence  of  sarcoma  and  its  differentiation  from 
other  forms  of  malignant  growth  is  usually  as  far  as  the  surgeon  ia 
able  to  go.    At  times,  the  histological  character  of  the  tumor  may  be 


SARCOMATA 


1183 


assumed  front  its  location;  for  iustance,  when  the  alveolar  processes 
are  the  seat  of  a  growth.  Lymphosarcomata,  chondrosarcomata,  and 
myxosarcomata  are  not  susceptible  to  clinical  differentiation.  On  the 
other  hand,  melanosarcomata  are  recognized  by  their  color,  and 
osteosarcomata  by  their  hardness  and  their  Icoation.  When  deeply  lo- 
cated inflammatory  exudates  (especially  gumma)  have  to  be  taken  into 
account,  it  may  be  necessary  to  explore  with  the  knife,  a  measure 
which  should  not  be  set  aside  in  favor  of  the  slower,  and,  after  all, 

less  satisfactory  serologic 
examination  and  anti- 
syphilitic  test  treatment. 
The  treatment  consists 
in  early  radical  removal 
of  (he  tumors,  including  a 
liberal  extent  of  healthy 
tissue.  This  should  be 
done  before  metastases 
occur.  "When  the  location 
of  the  process  permits,  the 
part  should  be  amputated 
at  as  great  a  distance 
from  the  tumor  as  pos- 
sible. 

Chondrosarcomata  and 
osteosarcomata  develop 
from  the  osseous  system, 
and,  at  times,  though 
rarely,  in  the  soft  parts. 
Chondrosarcomata. —  Chondrosarcomata  are  genetically  closely 
related  to  chondromata,  from  which  they  may  develop  and,  like  the 
latter,  are  characterized  by  the  formation  of  a  hyalin  ground  sub- 
stance. Unlike  chondromata,  they  contain  a  large  number  of  various 
kinds  of  round,  spindle  or  polymorphous  cells  arranged  in  groups  and 
columns,  surrounded  by  small  and  large  islands  of  cartilage  substance. 
Isolated  groups  of  cartilage  cells,  devoid  of  a  capsule,  lie  within  this 
ground  substance. 

The  cut  surface  of  a  chondrosarcoma  does  not  present  the  homo- 
geneous appearance  of  the  sectioned  (not  degenerated)  chondroma. 
The  cartilaginous  sections  appear  as  opalescent,  bluish  areas,  sur- 
rounded by  soft,  vascular  sarcoma  tissue.     Calcification  of  the  carti- 


FlG,    572. —  CHONDROSARCOirA. 
Sarcoma   cells   in    center   of   cartilage. 


1184 


TUMORS 


lage  is  indicated  by  the  appearance  of  white  zones ;  ossification,  by  the 
formation  of  hard  areas  (chondrosarcoma).  Large  cystic  spaces  are 
found  when  regressive  changes  occur. 

Chondrosarcomata  grow  rapklhj  and  reach  great  dimensions.    They 
destroy  the  soft  parts  and  the  bone,  and  are  soon  attended  with,  the 
formation  of  mestastases  in  which 
cellular   proliferation   is  so   rapid 
that  usually  there  is  not  time  for 
the  development  of  cartilage. 

OsTEOSARCOMATA.  —  Ostcosarco- 
mata,  or  ossifying  sarcomata,  in- 
clude those  that  contain  hony  tissue 
or  its  performed  elements,  not  those 
originating  from  the  connective  tis- 
sue of  bone.  A  clear  line  of  demar- 
cation in  this  connection  is  not 
always  possible,  as  connective  tis- 
sue sarcomata,  through  reactive 
proliferation  of  the  periosteum, 
may  contain  bone  tissue  elements. 

Osteosarcomata  are  predomi- 
nantl}^  situated  at  the  ends  of  the 
long  tubular  hones,  but  they  are 
also  found  in  the  pelvic  hones,  the 
scapula,  the  clavicle,  the  sternum, 
the  bones  of  the  skull,  the  jaws,  and 
the  ribs,  the  short  tuhular  hones, 
the  vertehrre,  the  calcaneum  and 
the  patella. 

Periosteal    osteosarcomata    are 
most    often    composed    of    spindle,   Fig.  573.— Periosteal  Osteosarcoma 
mixed  with  round  and  giant  cells,  of  the  Humerus. 

between   which    hony    Suhstance    in       (Symmcrs,  Belle\^ie  Hospital  case.) 
the  form  of  regular  or  irregular 

lamellae  is  deposited.  When  tumors  contain  only  delicate,  uncalcified 
osteoid  lamellae,  they  are  called  osteoid  sarcomata.  They  gradualh' 
merge  into  the  less  malignant  tumors  which  contain  broad,  uncalcified 
lamellae  of  a  cartilaginous  character  containing  irregular  stellate  cells, 
and  are  called  osteoid  cKondrom,ata. 


SARCOMATA  1185 

Tlie  tumor  mass  is  rarely  entirely  ossified.  Ossification  is  farthest 
advanced  in  tlie  older  central  portion,  while  the  periphery  is  rich  in 
cellular  elements,  and  hone-like  areas  alternate  with  those  consisting  of 
osteoid  and  chondroid  tissue.  The  bone  lamellae  are  often  studded 
with  osteoblasts  and  form  a  fine,  spongy  meshwork  containing  sarcoma 
cells  and  blood  vessels,  which  take  the  place  of  the  normal  marrow ; 
or  they  are  so  arranged  that  the  bone,  after  maceration,  is  embedded 
in  radiating-  or  willow  basket-like  thorns  and  needles. 

Periosteal  osteosarcomata  appear,  at  first,  as  circumscribed  nodules 
of  varying  consistency^,  surrounded  b}'  a  thin  layer  of  periosteum.  In 
accord  with  their  origin,  they  are  mo.t  commonly  found  in  the  region 
of  the  metaphyses  of  the  long  tubular  hones;  later,  as  they  extend, 
they  surround  large  portions  of  the  entire  bone,  converting  it  into  a 
maliormed,  cluh  shaped  mass.  When  their  growth  is  slow  and 
attended  with  much  bony  formation,  the  corticalis  is  only  superficially 
destroyed  and  the  site  of  their  attachment  to  the  bone  is  surrounded 
b}'  a  layer  of  osteoph^-tes.  Rapidly  growing  sarcomata  break  through 
the  investing  periosteal  capsule,  especially  at  the  attachments  of 
muscles  and  tendons,  and  infiltrate  the  soft  parts;  they  also  extend 
through  the  corticalis  by  way  of  the  Haversian  canals,  so  that  these 
are  gradually  obliterated  by  ossifj'ing  tumor  tissue.  In  this  way  the 
process  gains  access  to  the  medullary  canal,  where  itsi  light  color  read- 
ily distinguishes  it  from  normal  uninvaded  medulla.  In  advanced 
cases,  therefore,  it  is  not  easy  to  determine  whether  a  given  tumor  is 
periosteal  or  myelogenous  in  origin.  While  the  articular  cartilages 
resist  invasion  for  a  long  time,  the  joint  capsule  is  readily  perforated 
and  thus  the  process  gains  access  to  the  joint  cavity. 

The  clinical  picture  presented  by  periosteal  osteomata  closely  resem- 
bles that  of  the  myelogenous  form.  However,  it  is  not  covered  by  the 
bony  shell  common  to  the  early  stages  of  the  central  form. 

Myelogenous  osteosarcomata  and  myeloid  sarcomata  most  commonly 
occur  in  the  spongiosa  of  the  ends  of  the  long  tuhular  hones  (in  young 
persons,  they  appear  in  the  metaphyses  more  often  than  in  the  epi- 
physes), though  none  of  the  bones  are  exempt.  The  lotver  jaw,  the 
metacarpal  and  metatarsal  hones,  the  hones  of  the  sk^ill,  the  vertehrcp, 
and  the  pelvic  hones  are  most  frequently  involved.  They  have 
appeared   in  multiple   form   in  connection  with   osteitis  deformans. 

Myelogenous  sarcomata  are  composed  of  spindle  cells  or  of  vari- 
ously shaped  large  cell  forms,  and  contain  gia7it  cells  in  greater  num- 
ber than  the  periosteal  sarcomata.     Bone  formation  is,  as  a  rule, 


1186 


TUMORS 


DOMINATED  BY  CELLULAR  PROLIFERATION.  The  great  Vascularity  of 
these  tumors  (especially  as  to  arterial  supply)  may  cause  pulsation 
and  a  hruit,  so  that  they  have  been  called  done  aneurisms.  Hemor- 
rhages frequently  occur  within  the  tumor  mass;  these  lead  to  the 
deposit  of  pigment  and  yellowish  and  reddish  brown  discoloration  of 
the  tissues.  When  areas  of  this  sort  undergo  softening,  cysts,  the 
walls  of  which  contain  bone  lamellae,  are  formed. 


Fig.  574. —  Myelogenous  Sarcoma  of  Femur  (Ewing). 

As  a  rule,  myelogenous  sarcomata  grow  hy  expansion  for  a  long 
time  and  are,  therefore,  relatively  ienign  in  character.  This  is  espe- 
cially true  of  tumors  rich  in  giant  cells  with  a  considerable  admixture 
of  spindle  cells  and  a  liberal  amount  of  connective  tissue  and  bony 
ground  substance  {giant  cell  sarcoma).  The  affected  bone  is  thick- 
ened, but  this  is  not,  as  in  inflammatory^  lesions,  due  to  thickening  of 
the  corticalis ;  on  the  contrary,  the  growth  of  the  tumor  destroys  the 
cortiealis,  which  is  replaced  by  proliferation  from  the  periosteum.    In 


SARCOMATA 


1187 


this  way  the  bone  loses  its  resistance  where  the  central  tumor  is  located 
and  consequently  fractures  readily  (spontaneous  fracture).  At  times, 
especially  in  sarcoma  of  the  jaws,  palpation  of  the  thin  bone  shell 
elicits  parchment -like  crackling. 

When  the  periosteal 
bone  formation  does 
not  keep  pace  with  the 
absorption  from  within, 
the  shell  of  the  tumor 
is,  sooner  or  later,  per- 
forated and  the  process 
extends  far  into  the 
soft  parts  and  the 
joints,  and  encircles 
the  bones,  forming  a 
proliferating  t  u  m  o  r 
mass,  the  infiltrating 
growth  of  which  now 
becomes  manifest  and 
metastases  soon  de- 
velop. 

This  transition  from 
comparative    hen igniti/ 
into    the    malignant 
stage    does    not    occur 
with  the  same  rapiditg 
in  all  cases.    Soft  cellu- 
lar myelogenous  sarco- 
mata    (the     so-called 
medullary  form)    per- 
forate    most     rapidly 
and  take  on  aii  infiltrat- 
ing   character    sooner 
than   the   hard   forms. 
This  is  especially  true 
of  giant  cell  sarcomata 
which,  even  after  gaining  access  to  the  soft  parts,  may  continue  to 
grow  by  expansion,  though,  because  of  their  vascularity,  they  possess 
a  tendency  to  metastasize. 
Of  the  clinical  manifestations,  drawing  pain  and  rapid  thickening 


Fig. 


575. —  Large  OsTEOSARCOJrA  of  Upper  End  of 
Humerus;  Amputation  Specimen. 


1188  TUMORS 

of  hone  are  the  first  symptoms.  To  these  maj^  be  added  the  occur- 
rence of  spontaneous  fractures  and  serous  synomal  exudation,  which 
are  difficult  to  interpret  when  they  are  the  primary  symptoms.  The 
more  rapidly  the  tumor  grows,  the  earlier  disturbances  of  function 
appear,  due  to  the  involvement  of  nerves  and  muscles  and  to  circulat- 
ing disturbances  from  pressure  on  important  veins,  which  help  to  deter- 
mine the  seat  of  the  tumor.  Pressure  symptoms  are  especially  marked 
in  connection  wnth  tumors  of  the  skull  and  the  thorax  which  compress 
the  brain  and  the  lung.  After  the  skin  is  perforated,  deep  ulcers  make 
their  appearance.  Ulcers  of  this  sort  bleed  very  readily  and  are  often 
infected. 

The  diugnosis  of  advanced  cases  of  osteosarcoma  is  based  on  the 
appearance  of  a  large,  rapidly  growing  tumor  associated  with  the  bone, 
the  surface  of  which  is  connected  with  the  soft  parts  and  is,  therefore, 
not  clearly  defined  in  outline.  Extension  of  the  growth  to  a  given 
muscle  may  be  observed  by  noting  its  involvement  as  the  process  pro- 
gresses. The  development  of  metastases  in  the  lung,  with  recognition 
of  the  bloody  pleural  effusion  is,  of  course,  diagnostic.  To  establish 
the  origin  of  a  given  tumor,  i.  e.,  whether  it  is  primarily  periosteal  or 
myelogenous,  or  whether  it  began  in  the  soft  parts,  and  whether  the 
growth  under  consideration  is  an  osteo-,  chondro-,  osteoid,  or  connective 
tissue  sarcoma,  is  rareh'  possible  from  its  location  and  consistence, 
nor  is  this  of  great  clinical  importance.  The  mj'elogenous  form  is 
most  often  met  with,  and  its  presence  is  frequently  announced  by  the 
occurrence  of  a  spontaneous  fracture. 

In  the  early  stages,  the  diagnosis  is  extremely  difficult.  The  sym- 
metrical thickening  of  myelogenous  sarcoma,  at  times  attended  with 
hydrops  of  the  contiguous  joint,  bears  considerable  resemblance  to 
chronic  inflammatory  processes,  such  as  suppurative,  tuberculous,  and 
gummatous  osteitis,  especially  when  the  last  occurs  in  situations  where 
sarcomata  commonly  develop.  Nor  is  the  temperature  course  of  much 
help,  as  sarcoma  growth  is  often  attended  with  fever.  The  nodular 
form  of  small  periosteal  sarcomata  presents  a  picture  very  similar  to 
that  of  fibroma,  chondroma,  or  osteoma.  While  spontaneous  fractures 
argue  for  sarcoma,  their  occurrence  is  not  restricted  to  it.  Midtiple 
lesions  are  rarely  sarcomatous,  but  they  ma}'  be  so. 

In  all  cases  of  this  sort,  clinical  observation  (which  for  obvious 
reasons  must  not  be  too  long  extended)  is  essential  to  the  decision. 
When  the  skin  becomes  red  over  a  rapidly  growing  tumor,  the  assump- 
tion that  a  suppurative  osteomyelitis  or  a  gumma  is  present  is  justi- 


SARCOMATA  1189 

fied.  Bone  tuberculosis  is  not  a  rapidly  extending  process,  npr  is  the 
red  infiltration  of  the  skin  which  it  causes  before  perforation,  attended 
with  a  sense  of  warmth  to  the  touch,  while  sarcoma  may,  because  of 
its  vascularity,  impart  a  sense  of  warmth  to  the  hand,  though  it  never 
causes  redness.  When  large  doses  of  iodin  are  administered  during 
this  period  without  any  retrogression  of  the  process,  the  diagnosis  of 
chronic  suppurative  osteomyelitis  is  permissible.  When  extension  of 
the  tumor  is  not  attended  with  evidence  of  inflammation  of  the  skin, 
the  process  is  no  doubt  confined  to  the  bone  which,  when  palpation 
and  the  X-ray  plate  reveal  the  presence  of  a  hone  shell,  is  probably 
myelogenous.  Bapid  growih  of  the  tumor  indicates  sarcoma  as  against 
benign  tumors  (fibroma,  chondroma,  echiuoccocus) .  However,  obser- 
vation with  respect  to  the  behavior  of  a  tumor  is  not  always  of  great 
help,  as  it  cannot  he  safely  carried  heyond  two  weeks. 

The  X-ray  plate  is  of  great  diagnostic  value.  It  permits  of  recog- 
nition of  the  form  of  the  exostoses,  which  are  sharply  outlined  against 
th3  surface  of  the  bone.  Periosteal  sarcomata  throw  an  irregular 
cloudy  shadow,  the  densitj'  of  which  varies  with  the  extent  of  bony 
content  and  their  borders  merge  gradually  with  the  contour  of  the 
bono,  which  is  not  clearly  defined  at  the  base  of  the  tumor.  Myelo- 
genous sarcomata  appear  in  the  bone  as  light  areas  framed  in  the 
surrounding  thinned  out,  distended,  corticalis.  However,  since  these 
light  areas  simply  indicate  the  absence  of  bone  tissue,  they  are  also 
present  in  eases  of  abscesses  and  cysts  and  are,  therefore,  not  distinc- 
tive. On  the  other  hand,  the  preservation  of  a  thin,  hony  shell  argues 
strongly  against  inflammatory  foci  of  all  kinds,  even  against  the  tuber- 
culous, at  least  in  the  long  tubular  bones.  The  symmetrical  outline  of 
the  tumor  shadows  argues  against  chondroma  and  cysts.  Similar 
conditions  permit  of  a  conclusion  in  connection  with  spontaneous  frac- 
tures, in  which  gumma  must  also  be  taken  into  account.  The  latter 
are  attended  with  the  formation  of  irregular  hyperostoses  of  the 
corticalis  in  the  vicinity  of  the  lesion,  and  are  not  rarely  a  part  of  a 
number  of  lesions  situated  in  the  various  bones  of  the  body. 

When  a  rapidly  growing  sarcoma  invades  a  joint  early  in  its  devel- 
opment, the  diagnosis  is  not  readily  made.  The  "doughy  feel"  of  the 
region  of  the  joint  and  its  spindle  form,  is  frequently  seen  in  joiiit 
tuherculosis  and  in  cases  of  hlood  joint.  Aspiration  of  the  latter 
reveals  the  nature  of  the  effusion,  but  does  not  clear  up  its  cause. 
When  the  X-ray  picture  does  not  define  the  character  of  the  lesion, 
the  progress  of  the  growth  as  it  extends  well  beyond  the  confines  of  the 


1190  TUMORS 

joint  makes  palpable  a  tumor  attached  to  the  bone,  which,  together 
with  the  manifest  circulatory  disturbances  now  apparent,  is  in  strong 
contrast  with  the  atrophy  coincident  to  joint  tuberculosis  and  presents 
considerations  which  help  to  make  .the  diagnosis. 

In  children,  myelogenous  soft  sarcomata  of  the  epiphyses  and  meta- 
physes  may  present  the  clinical  picture  of  epiphyseal  separation  and 
are  also  easily  confused  with  inflammatory  lesions  in  this  situation, 
especially  when  the  pus  distended  capsule  fluctuates. 

Aneurisms  in  the  axilla,  popliteal  space,  and  sternum  must  also  be 
differentiated  from  sarcomata  in  these  situations.  This  is  not  an  easy 
matter. 

Metastases  of  lymph  nodes,  which  also  occur  in  connection  with 
sarcomata  of  bones  (Nasse^),  do  not  possess  value  as  an  early  diagnostic 
sign,  as  the  glands  are  often  enlarged  from  hyperplasia  due  to  the 
absorption  of  the  products  of  disintegration  derived  from  the  tumor. 

The  prognosis  in  sarcomata  of  the  skeleton  is  grave.  Even  those 
growths  that  are  less  malignant  ultimately  lead  to  the  development  of 
metastases  and  the  destruction  of  tissue. 

In  the  treatment  of  sarcomata  of  cartilage  and  bone  which  have  not 
yet  formed  metastases  there  is  no  doubt  of  the  justification  of  complete 
extirpation.     However,  as  sarcomata  do  not  all  possess  the  same 

DEGREE  OF  MALIGNANCY,  THE  EXTENT  OF  THE  OPERATION  IS  NOT  SO  READ- 
ILY DECIDED  UPON.  A  DECISION  IN  THIS  CONNECTION  IS,  IN  A  DEGREE, 
INFLUENCED  BY  THE  KIND  OF  CELLS  OF  W^HICH  THE  TUMOR  IS  COMPOSED, 
IN  SO  FAR  AS  THIS  CAN  BE  DETERMINED.  In  A  GENERAL  WAY,  THOSE 
COMPOSED  OF  GIANT  CELLS  ARE  THE  LEAST  MALIGNANT,  WHILE  THOSE  OP 
THE   SMALL   ROUND    CELL   VARIETY  ARE   EXTREMELY   SO.      In    addition   tO 

this,  the  mode  and  the  rapidity  of  the  tumor  growth  are  indicative  of 
its  menace.  Completely  encapsulated  tumors  that  grow  l)y  expansion, 
as  is  the  case  in  giant  cell  sarcomata,  which  are  readily  recognized 
by  their  brownish  red  color,  may  be  removed  with  the  periosteal  ele- 
vator and  scoop  without  great  fear  of  subsequent  return  of  the  lesion. 
However,  even  when  encapsulated  tumors  are  enucleated  in  this  way  a 
portion  of  the  contiguous  bone  tissue  (the  mother  bed  of  the  tumor) 
should  also  he  removed.  This  is  accomplished  with  the  chisel  and  saw, 
and  when  the  shell  of  the  residual  portion  of  bone  is  very  thin  it  is  best 
to  resect  the  entire  zone  of  the  hone.  A  lateral  bridge  of  bone  should 
be  left  behind  only  when  one  side  of  it  is  still  moderately  thick. 

The  method  has  succeeded,  even  in  cases  of  central  and  periosteal 
sarcomata   (when  the  soft  parts  were  not  involved),  which  require 


SARCOMATA  1191 

removal  of  considerable  portions  of  bone  (v.  Mikulicz/^  Nasse,"  and 
others).  The  procedure  is  followed  by  a  certain  feeling  of  security 
only  in  cases  of  giant  cell  sarcomata;  in  other  forms  secondary  nodules 
are  often  present  in  the  medulla  of  contiguous  sectors  of  hone 
(Koenig^^).  The  remaining  portions  of  the  bone  may  be  brought  in 
apposition,  or  the  residual  defects  may  be  bridged  by  hone  transplants. 
When  the  soft  parts  in  the  limbs  are  invaded  by  extension  from  the 
bone,  amputation  must  be  resorted  to.  On  the  trunk,  head,  and  neck, 
the  tumor  and  extensive  areas  of  contiguous  tissues  must  be  excised. 
For  instance,  in  sarcoma  of  the  orbital  cavity,  the  eye  must  be  removed, 
and  when  the  thorax  or  abdominal  wall  are  involved,  these  must  be 
extensively  sacrificed.  Nasse'^  has  shown  that  tumor  masses  soon 
invade  the  muscles,  and  he  pleads  that  operative  removal  be  under- 
taken early  and  that  amputation  be  executed  heijond  the  insertions  of 
the  affected  muscles,  i.  e.,  central  to  the  proximal  joint.  In  tumors  of 
the  forearm,  the  limb  is  amputated  through  the  arm ;  in  those  of  the 
leg,  through  the  thigh ;  for  relief  of  sarcoma  of  the  humerus,  amputa- 
tion through  the  shoulder  girdle  is  performed,  and,  when  the  femur  is 
affected,  the  hip  joint  and  the  muscles  arising  from  the  pelvis  are 
removed. 

Nevertheless  the  outlook  in  cases  in  which  the  growth  has  extended 
to  the  soft  parts  is  very  unfavorable.  Reinhardt-^^  estimates  that  only 
eighteen  per  cent  of  cases  of  sarcoma  of  the  long  bones  permanently 
recover  after  amputation.  This  unfavorable  outcome  is  not  due  to 
recurrence,  but  follows  from  the  development  of  metastases,  especially 
in  the  lung.  These  often  develop  so  soon  after  the  operation  that  it 
would  seem  probable  that  they  were  already  present  when  the  measure 
of  relief  was  undertaken. 

The  treatment  of  inoperable  sarcomata  is  taken  up  farther  on  in 
this  part. 

Chondro-  and  osteosarcomata  developing  in  soft  parts  are  of  little 
surgical  significance.  TTiey  occasionalh'  arise  from  the  intermuscular 
connective  tissue,  in  the  mammary  gland,  the  spermatic  cord  and  the 
fasciae,  and  form  a  part  of  mixed  tumors. 

Sarcomata  Composed  of  Cells  Resembling  Lymph  Corpuscles. —  The 
term  lymphosarcoma  should  be  applied  to  those  tumors  which  have 
their  prototype  in  or  develop  fram  lymphatic  tissue  proper  (lymph 
nodes,  follicles  of  the  mucosa  and  .spleen).  It  should  not  be  used  in 
connection  with  tumors  that  arise  primarily  from  the  connective  tissue 
or  recticulum  of  the  lymph  nodes ;  these  are  really  fibrosarcomata. 


11^2 


TUMORS 


The  distinction  between  lymphatic  sarcoma  and  hyperplastic  pro- 
■iferation  is  not  clear.  The  collective  terms  maligna^it  lymphoma  and 
lymphocytoma  have  been  applied  to  the  peculiar  proliferation  of 
lymph  nodes  first  described  by  Hodgkins^^^  in  1832,  which  is  called 
malignant  lymphoma  by  Billroth/^  pseudoleukemic  lymph  7iodes  by 
Cohnheim/^  and  aleukemic  malignant  lymph  nodes  by  Orth/'^  and  is 
regarded  as  hyperplastic  proliferations  distinct  from  sarcoma. 

Although  the  many  transitions  bespeak  an  alliance  between  lympho- 
sarcomata  (aleukemic)  and  malignant  lymphomata,  it  is  nevertheless, 
from  a  clinical  stand- 
point, desirable,  in  view 
of  the  indefinite  causa- 
tion, to  keep  the  two 
processes  separated. 

Lymphosarcomata. — 
Lymphosarcomata  are 
composed  of  cells  re- 
semhling  lymphocytes, 
which  form  the  main 
mass  of  the  new  growth 
(therefore  lymphocyto- 
mata  by  Ribbert^)  and 
are  regularly  distributed 
throughout  a  fine  vascu- 
lar reticulum  covered  by 
endothelium.  The  struc- 
ture of  normal  lymph- 
adenoid  tissue  is  not  entirely  simulated  by  the  growth,  as  the  latter  is 
devoid  of  lymph  channels  and  lymph  follicles.  The  extent  of  the 
density  of  the  reticulum  establishes  the  soft  or  hard  consistence  of  the 
tumor. 

Lymphosarcomata  always  originate  from  normal  lymphatic  tissue, 
above  all  from  the  lymph  nodes,  of  which  those  of  the  neck  (Fig.  577), 
the  axilla,  the  retroperitoneal  tissues,  and  the  mediastinum  are  most 
often  invaded.  The  other  parts  involved,  at  times,  are  the  tonsils, 
the  lymphatics  of  the  pharynx,  the  follicles  of  the  g astro-intestinal 
canal,  the  thymus,  and  finally  the  tissues  of  the  spleen  and  the  hone 
marrow. 

In  young  persons  the  process  develops  from  a  single  lymph  node 
or  in  a  lymphatic  organ  and  grows  very  rapidly,  appearing  in  either 


Fig.   576. —  Lymphosarcoma. 


SARCOMATA 


1193 


the  hard  or  the  soft  form.  It  soon  perforates  the  capsule  of  the 
node,  infiltrates  the  lymph  spaces,  and  gains  access  to  the  surrounding 
tissues.  In  this  way,  large,  partially  nodular  tumors,  the  borders  of 
which  are  poorly  defined,  involve  the  superimposed  skin  and  impart 
a  bluish  color  to  it,  while  the  deeper  parts  become  necrotic. 


Fig. 


Lympiiosarcomata  of  the  Neck  and  Left  Axillary  Fossa. 


The  clinical  uianifcslaiions  of  this  exceedingly  malignant  growth 
depend  entirely"  upon  its  location,  i.  e.,  as  to  whether  the  trachea,  the 
esophagus,  the  lung,  the  heart  (in  mediastinal  tumors  arising  from 
the  thymus  gland  or  from  the  lymph  nodes),  important  nerves  or  large 
blood  vessels  are  involved. 

When  the  location  of  the  tumor  does  not  cause  disturbances,  it 


1194  TUMORS 

destroys  the  host  as  the  result  of  hematogenous  metastases,  which  make 
their  appearance  in  the  lu)ig,  the  liver,  the  spleen,  and  the  skin.  The 
metastatic  foci  take  on  the  nodular  and  the  diffuse  forms  and  may 
infiltrate  an  entire  organ,  such  as  the  liver.  The  progress  of  the 
process  is  attended  with  grave  changes  in  the  character  of  the  blood 
{lymphcmia).  In  some  cases  the  entire  lymphatic  system  is  the  seat 
of  proliferative  changes  presenting  transitional  stages  merging,  on  the 
one  hand,  into  the  formation  of*  leukemic  and,  on  the  other,  of 
aleukemic  lympJiomata  (Conan^'). 

The  diagnosis  of  lymphosarcoma  rests  on  its  rapid  growth  and  the 
symptoms  produced  by  its  location.  Diagnostic  separation  from  otlier 
sarcomata  of  the  lymph  nodes  or  soft  parts  is  not  attainable.  Lympho- 
sarcoma differs  clinically  from  malignant  lymphoma  in  its  symmetrical 
growth  and  in  the  fact  that  it  is  attached  to  the  surrounding  tissues. 
Microscopicallj",  they  do  not  differ  from  each  other. 

The  treatment  consists  in  early  extensive  extirpation,  although 
recurrences  follow  in  most  cases. 

Malignant  Lymphomata. —  Malignant  lymphomata  are  distinct 
from  lymphosarcomata  in  the  clinical  course  they  follow. 

Although  the  disease  is  characterized  by  proliferation  of  the  lymph- 
atic organs,  especially  the  lymph  nodes,  and  the  microscopical  picture 
is  identical  in  both  lesions  (except  for  a  tendency  in  the  latter  to 
disintegrate),  two  differences  are  apparent:     Malignant  lymphoma 

DOES  NOT  PERFORATE  THE  GLAND  CAPSULE,  AND  IT  PROGRESSIVELY  INVADES 
THE  ENTIRE  LYMPHATIC  SYSTEM,  INCLUDING*  THE  SPLEEN,  AND  MAY 
INVADE  THE  BONE  MARROW. 

The  appearance  of  foci  in  the  liver,  the  lung,  the  kidney,  and  hone 
marrow  would  justify  classing  malignant  lymphoma  with  genuine 
tumors,  were  it  certain  that  the  development  of  foci  was  metastatic, 
but  it  is  possible  that  they  may  have  developed  from  preexisting 
lymphatic  nodules.  On  the  other  hand,  the  disease  bears  a  resemblance 
to  leukemia,  inasmuch  as  the  proliferation  in  the  lymphatic  system  is 
characterized  by  progressive  enlargement  of  the  l^^mph  nodes  with  the 
formation  of  so-called  heteroplastic  nodules  in  the  various  organs. 
However,  the  blood  picture  is  not  identical  in*  lymphatic  leukemia; 
the  leukocytes  are  greatly  increased,  reaching  150,000  or  more  per 
c.cm.,  and  there  is  a  definite  lymphocytosis  which  reaches  from  90  to 
99  per  cent,  while  in  malignant  lymphoma,  the  number  of  leukocytes 
is  normal  or  only  slightly  increased  (K.  Ziegler^^). 

Aleukemic  malignant  lymphomatosis   [Hodgkin's  disease,  lympho- 


SARCOMATA 


1195 


granulomatosis)  occurs  most  often  in  young  persons  and  begins  with 
painless,  gradual  swelling  of  a  group  of  lymph  nodes,  usually  appear- 
ing first  in  the  neck  (Fig.  578).  The  individual  nodes  grow  into  soft 
or  hard  nodules  varj-ing  in  size  from  a  walnut  to  an  apple,  so  that  the 
entire  mass  is  irregularly  lobulated.  On  section,  the  glands  are  homo- 
geneous and  grayish  red  in  color^  the.  distinction  between  cortex  and 
medulla  being  lost.  There  is  no  tendency  to  regressive  changes  nor 
to  break  through  the  capsule  of  the  lymph  nodes  and  invade  surround- 
ing tissues;  therefore,  the  separate  nodes  can  he  palpated  beneath  the 
normal  skin  and  freely  moved  upon  one  another.     Growth  occurs  in 

intermittent  exacer- 
bations, and  at  times 
is  stationary.  While 
proliferation  is  ex- 
tending to  neighbor- 
ing lymph  nodes,  the 
lymphatic  appara- 
tus of  the  pharynx, 
the  gasfro-intestinal 
canal,  the  spleen, 
and  the  thymus  are 
also  invaded  and 
give  rise  to  general 
systemic  disturb- 
ances of  varying 
magnitude.  These 
consist  in  intermit- 
tent fever,  increas- 
ing anemia  and- 
weakness  which  are 
caused  by  digestive  disturbances  (vomiting  and  diarrhea)  when  the 
stomach  and  gut  are  involved,  and  to  respiratory  difficulties  and 
dysphagia  when  the  pharynx  is  invaded.  The  picture  is  usually  finally 
closed  by  a  fatal  outcome  within  two  or  three  months. 

The  diagnosis  is  difficult  when  only  a  single  group  of  lymph  nodes 
is  attacked.  Leukemic  lymphomatosis  is  excluded  by  the  blood  pic- 
ture. The  mobility  of  the  masses  assists  in  separating  lymphosarcoma. 
Gummataiis  lymph  nodes  exhibit  evidence  of  inflammation  and  soon 
break  down.  Tuberculous  adenitis  is  more  common  in  the  young,  is 
frequently  primarily  bilateral  and  soon  undergoes  regressive  changes 


Fig.    578.- 


HoDGKix's    Disease;    Lymphogranulo- 
matosis Colli. 


1196  TUMORS 

leading  to  abscess  formation  and  the  establishment  of  fistulae.  As  a 
rule,  the  problem  arises  only  in  the  early  course  of  the  process  and 
may  not  be  correctly  solved  at  once. 

There  are,  however,  rare  forms  of  lymph  node  tuberculosis  in  v^^hich 
the  glands  do  not  undergo  softening  and  the  entire  glandular  system 
is  involved.  This  bears  a  strong  resemblance  to  the  picture  presented 
by  malignant  lymphomatosis,  the  more  so  as  the  character  of  the 
process  is  recognized  only  by  the  microscopical  discovery  of  the  tuber- 
cle bacilli  or  of  giant  cells.  A  connection  between  the  two  lesions  is 
assumed  by  Sternberg,^^  Oskar  Meyer,-°  and  others,  while  Dietrich,^^ 
Borst,*  and  others  oppose  this  view.  Fraenkel,  Much,^-  and  others 
found  a  bacillus  resembling  the  tubercle  bacillus  in  a  case  of  malignant 
lymphomatosis.  White-^  found  the  spirocheta  pallida  in  another.  It 
is  questionable  whether  these  are  to  be  regarded  as  the  excitants  in  the 
formation  of  lymphomata,  Ziegler,^^  Fraenkel,"  Sternberg^"). 

The  treatment  by  extirpation  of  the  glands  is  of  no  avail.  The 
administration  of  arsenic  in  increasing  doses  has  a  favorable  influence 
on  the  disease  (Billroth-^).  Th«  daily  injection  of  0.1  of  a  1  per  cent 
solution  of  acid  arsen  (Czerney,-'  v.  Winiwarter-**)  or  of  0.1  of  Fowler's 
solution  (v.  Zi(-ms>:en-' )  into  the  tumors  is  followed  by  shrinkage  of 
the  masses.  Repeated  exposure  to  the  X-ray  has  a  similar  effect. 
Complete  recovery  is  not  to  be  expected. 

To  the  group  of  lymphosarcomata,  the  rare  and  peculiar  form  of 
tumors  called  myelomata  and  chloromata  should  be  added. 

Multiple  Myelomata. —  Multiple  myeloma  is  a  term  applied  to  a 
rare  process  appearing  simultaneously  in  various  portions  of  the 
osseous  system,  especially  in  the"  red  bone  marrow.  The  lesion  con- 
sists of  a  nodular,  circumscribed,  soft,  grayish  red  proliferation,  which 
is  regarded  as  a  focal  hyperplasia  of  the  bone  marrow  and  also  as  a 
Ij-mphosarcoma.  It  is  not  characterized  hy  a  tendency  to  extend 
locally,  nor  does  it  form  metastases.  The  lesions  remain  confined  to 
the -osseous  system,  which  is  often  severely  damaged  by  the  process  and 
undergoes  deformation  (especially  in  the  vertebrae)  ;  in  the  skull  they 
cause  extensive  defects;  they  are  often  responsible  for  spontaneous 
fractures  (Hoffmann,^''  Permin,^^  v.  Verebely,^"  Yellinek^^). 

The  disease  appears  late  in  life,  is  attended  with  fever  and,  under 
the  picture  of  pernicious  anemia,  soon  ends  in  death.  Winkler^^  and 
Wieland^^  seem  to  have  shown  that  a  peculiar  albumose,  present  in  the 
urine,  is  derived  from  the  lesion  in  bones. 

Chloromata. —  Chloromata  are  also  multiple  neoplasms  composed 


SARCOMATA 


1197 


of  lympliadeuoid  tissue.  They  appear,  usually  in  children  and  young 
persons,  in  the  form  of  firm,  and  at  times,  soft  tumors  of  the  periosteum 
of  the  bones  of  the  skull  and  face  (especially  the  temporal  and  sphenoid 
bones,  upper  jaw  and  orbit),  the  sternum,  the  rihs,  the  vertehrce  and 
the  long  tuhular  hones.  Like  the  very  malignant  forms  of  sarcomata, 
they  grow  rapidly  and  metastasize  and  differ  from  sarcomata  only  in 
the  light  green  or  gray  green  color  of  their  tissues,  which  colors  also 
appear  in  the  metastases.  V.  Recklinghausen^'  ascribes  the  color  to 
the  parenchyma;    Chiari'"'  and  Huber-^'^  to  the  fat  pigment  they  con- 


Fig.  579. —  Myxosarcoma. 
a,  Myxomatous  tissue;   b^  columns  of  cells;   c,  fibrous  tissue   (after  Ziegler). 


tain.  The  lesions  are  attended  with  a  leukemic  state  of  the  blood 
(MacCallum-).  Meixner^'  reports  a  case  at  great  length  (see  bibli- 
ogpaphy).     The  complete  literature  is  collected  hy  Roman.'^ 

Sarcomata  Originating  from  Mucous  Membranes  —  Myxomata,  Myxo- 
sarcomata. —  These  tumors  consist  of  soft,  often  slightly  fluctuating, 
colloid  tumor  masses  which  on  section  present  a  yellowish  or  grayish 
red,  translucent  surface  from  which  a  tenacious  fluid  may  he  ex- 
pressed: the  flniid  contains  mucin.  The  growth  has  its  prototype  in 
AVliarton's  jelly  (in  the  umbilical  cord)  and  in  the  retina  of  the 
eveball. 


1198  TUMORS 

The  mass  represents  an  early  embryonic  stage  of  connective  tissue 
development. 

Histologically,  these  tumors  are  found  to  be  composed  of  polymor- 
phous stellate  cells  contained  in  a  homogeneous,  slightly  granular  or 
striated  mucoid  ground  substance,  which  is  very  vascular  and  presents 
an  occasional  giant  cell. 

Myxomata. —  Myxomata  are  rarely  composed  entirely  of  myxoma- 
tous tissue,  but  also  contain  connective  tissue  in  a  state  of  higher  or 
complete  development,  so  that  one  sector  stimulates  fibrmna  formation, 
while  another  resembles  sarcoma  tissue.  As  the  growth  develops  the 
structure  of  any  of  these  admixtures  may  dominate  the  histological 
picture,  forming  myxofibromata  and  myxosarcomata. 

Wheii  the  tumor  is  rich  in  blood  vessels  the  term  myxoma  telangiec- 
taticum  and  cavernosum  are  used.  When  myxoma  cells  are  infiltrated 
with  fat  they  are  called  myxoma  lipomatodes;  when  softening  occurs 
they  are  designated  as  myxoma  cysticum. 

Edematous  saturation,  which  occurs  in  m'any  connective  tissue 
tumors  (for  instance,  the  soft  fibromata  belonging  to  nasal  polypi,  the 
pendulous  fibromata  or  lipomata  of  the  surface  of  the  body),  must  not 
be  classed  with  the  myxomata.  The  delicate  fibrillar  ground  substance 
and  the  microscopic  mucin  reaction  (acetic  acid)  are  very  distinctive 
of  myxomata.  At  times,  areas  of  mucoid  softening  occur  in  large 
tumors  such  as  chondromata,  osteomata,  fibromata,  and  sarcomata; 
but  these  d-o  not  represent  true  myxomatous  tissue  formation.  In  order 
to  differentiate  the  latter  processes,  they  are  designated  as  fibroma 
myxomatodes  and,  when  the  tumor  is  composed  of  myxomatous  and 
fibroma  tissue,  it  is  called  a  myxofibroma  or  a  flbromyxoma,  in  accord 
with  its  dominant  tissue  structure. 

The  origin  of  myxomata  is  attributed  to  developmental  anomalies 
during  embryonic  life,  a  view  supported  by  their  frequent  appearance 
in  congenital  form.  Tumors  of  this  sort  have  been  observed  in  the 
cheek  by  Zahn,^^  and  in  other  situations,  such  as  the  umbilical  cord, 
by  a  number  of  other  writers  (v.  WinckeP°).  The  displaced  embry- 
onic myxomatous  tissue  does  not  develop  myxomata  alone,  but  also 
engenders  fibromata  and  sarcomata, 

Myxomata  form  nodular  and,  when  the  connective  tissue  trabeculae 
are  well  developed,  lobulated,  goodly  sized  tumors.  Like  all  sarcomata, 
they  occur  during  youth  or  in  early  middle  life  and  grow  with  varying 
rapidity.  In  some  instances  their  growth  is  expansive  in  character  for  a 
long  time ;  in  others,  cellular  proliferation  is  at  once  very  active     Pe^- 


SARCOMATA 


1199 


foration  of  the  capsule  occurs  promptly  and  the  surrminding  tissues  are 
soon  i)ifiltrated,  so  that  the  growth  becomes  poorly  defined,  perforates 
the  skin  and  goes  on  to  the  formation  of  metastases.  From  this  it  is 
easy  to  see  that  a  certain  number  of  tumors  are  'benign,  when  they  are 
called  myxomata,  while  others  are  very  malignant  and  are  called 
myxosarcomaia  in  a  narrower  sense. 

Myxosarcomata. —  Myxosarcomata  are  found  in  many  portions  of 
the  body.  They  attack  the  skin,  subcutaneous,  intermuscular  and 
retroperitoneal  connective  and  fatty  tissues,  the  bursas  and  fasciae 
the  periosteum  and  the  bone  marroic,  the  membranes  of  the  brain  and 
spinal  cord,  and  the  connective  tissue  of  nerves  and  of  various  organs 
(mamma,  ovary,  testicle,  spermatic  cord,  kidne}^  liver  and  lung). 
They  appear  most  often  in  the  thigh,  where  they  spring  from  the  skin 

or  fascia  or  intermus- 
cular tissue,  or  they 
begin  in  the  bursae  of 
the  knee  joint,  the 
amis  and  the  gluteal 
region.  In  the  external 
genitals,  the  neck,  the 
face,  and  the  scalp, 
they  usually  arise  from 
the  subcutaneous  tis- 
sues. In  the  orbit,  they 
originate  from  the 
fatty  tissue  or  from  the  optic  nerve.  -Mj'omata  of  the  peripheral  nerves 
may,  like  fibromata,  appear  in  multiple  form.  They  separate  the  fibers 
of  the  nerves  into  a  spindle  shaped  area  of  thickening  (Fig.  580).  In 
children,  rests  of  the  umbilical  cord  may  'be  the  point  of  origin  of  these 
tumors.  In  the  marrow  of  the  long  tubular  bones  the  process  is  usually 
cystic  in  character  and  causes  destruction  of  the  spongiosa.  Periosteal 
myxomata  appear  in  both  maxillae,  most  often  in  the  form  of  encap- 
sulated fibrous  tumors.  On  the  inner  aspects  of  the  jaws.ihey  form 
so-called  odontomata,  a  term  applied  to  tumori  arising  from  tooth  buds 
while  they  still  consist  of  mucoid  tissue.  Myxomata  of  the  endocar- 
dium possess  special  interest.  They  appear  as  lobulated  growths  in  the 
left  auricle,  on  the  intra-auricular  septum,  and,  at  times,  on  the  valves, 
and,  when  portions  are  carried  away  by  the  blood  current,  embolic  foci 
are  formed  (JacobsthaP^).  M^^xomatous  tissue  is  often  found  in 
mixed  tumors,  especially  in  the  parotid  gland. 

The  clinical  manifestations  of  myxomata  are  entirely  dependent  upon 


Fig.  580. —  Myxo-Ma  of  the  Eadial  Xerve. 

Kesection  followed  by  nerve  suture.  Healing  with 
complete  return  of  function.  No  recurrence  after 
five  years. 


1200  TUMORS 

their  location,  the  kind  of  tumor  present,  and  the  degree  of  growth  they 
attain. 

The  diagnosis  is  aided  by  the  peculiar  consistence  of  the  tumor,  when 
its  rapid  growth  and  indefinite  outline  create  the  impression  of  sarcoma. 
The  encapsulated  form  is  not  readily  differentiated  from  tuberculosis 
abscesses,  lipomata,  and  cysts  of  various  kinds.  When  aspiration 
reveals  the  presence  of  a  ropy,  viscid  fluid,  myxoma  should  be  suspected. 
This  does  not  exclude  other  cysts  that  contain  a  mucoid  substance,  such 
as  ranula,  the  hygromata  and  the  ganglia ;  however,  these  are  often 
recognized  by  their  location. 

The  treatment  varies  with  the  character  of  the  growth.  Slow  grow- 
ing, well  encapsulated  myxomata  may  be  '^ shelled  out;"  in  the  infil- 
trating form  extensive  resection  is  indicated,  and  when  the  tumor  is 
located  in  an  extremity,  high  amputation  is  justified.  In  nerve  myxoma, 
the  affected  sector  is  excised  and  the  ends  of  the  stumps  apposed  by 
sutures.  In  myxoma  of  the  optic  nerve,  the  eyeball  need  not  be  enucle- 
ated unless  it  is  involved  in  the  growth. 

Melanomata. —  Sarcomata  composed  of  pigment  cells  are  called 
melanomata  {malignant  melanoma,  melanosarcoma,  chromatophoroma) . 

These  tumors,  which  occur  primarilj^  only  in  the  eye,  on  the  skin, 
and  in  the  adjacent  mucous  membranes,  are  distinctive  in  color  and 
exceedingly  malignant.  They  occur  at  all  periods  of  life  and  appear 
in  the  form  of  round,  nodular,  fungiform  or  broadly  pedunculated 
tumors,  at  first  covered  by  delicate  epidermis,  which  soon  ulcerates 
and,  because  of  their  great  vascularity,  bleed  very  easily.  Tumors  of 
this  sort  are,  therefore,  soon  covered  with  crusts,  or  form  deep,  crater- 
like ulcers,  the  bases  of  which  are  colored  black  or  brown,  or  are  sepia 
tinted,  and  secrete  a  bloody,  usually  black,  fluid. 

The  consistency  of  melanomata  varies,  some  being  hard,  others  soft. 

ThB  characteristic  color  is  often  apparent  on  the  surface,  but  is 
always  clearly  defined  in  the  deeper  tissues.  TTie  color  varies  between 
yellowish  hrown,  deep  or  hlwe  Mack,  and  the  intermediate  shades. 
The  pigmentation  is  either  diffusely  disseminated  or  is  restricted  to  a 
certain  zone,  which  may  be  surrounded  by  tissue  of  normal  color, 
against  which  the  pigmented  sector  stands  out  in  striking  contrast. 
The  color  of  melanoma  Ls  very  distinct  from  the  dark,  brownish  red 
of  hemorrhagic  foci,  which  are  also  not  infrequently^  present  in  tumors 
of  this  sort. 

Softening  of  the  tumor  mass  leads  to  the  formation  of  hollow  spaces 
filled  with  black  fluid. 


SAKCOMATA 


1201 


Melanomata  of  the  posterior  sector  of  the  eye  begin  in  the  choroid 
those  of  the  anterior  originate  in  the  iris,  though  the  lesion  also 
arises  in  connection  with  the  deposits  of  pigment  at  the  edge  of 
the  cornea.  After  the  sclera  or  cornea  is  ruptured  the  process  ex- 
tends very  rapidly,  destroys  the  bulb,  and  appears  in  the  form  of 
nodular,  hard,  darkly  colored  masses  that  bleed  easily  and  soon  pro- 
trude from  the  orbital  cavity  and  invade 
the  cranial  cavit}'. 

On  the  skin,  most  malenomata  orig- 
inate m  congenital  pigmented  areas  and 
in  warty  nevi,  which  are  really  benign 
forms  of  melanoma.  The  lesion  begins, 
usually  after  some  irritative  influence, 
with  the  development  at  first  of  a  slowly 
growing,  and  later,  rapidly  growing, 
hrown  or  irownisk  black  nodule,  the  sur- 
face of  which  soon  becomes  fissured, 
ulcerates  and  bleeds  easily.  "When  it 
reaches  the  size  of  a  walnut,  small  bluish 
masses  (secondary  nodules)  that  shim- 
mer through  the  epidermis  appear  near 
the  primary  growth  and  are  concerned 
in  its  spread. 

The  contiguous  lymph  nodes  are  in- 
volved early  in  the  process,  and  on  sec- 
tion exhibit  black  or  brown  deposits. 
The  prompt  appearance  of  general  de- 
bility, anemia,  and  disturbed  function  of 
the  vital  organs  indicate  the  formation  of 
metastases  throughout  the  body. 

As  pigmented  moles  and  warts  are  most 
often  located  in  the  skin  of  the  face  and 
extremities,  so  also  melanomata  most  com- 
monly develop  in  these  situations.  They  are  frequently  found  on  the 
flexor  sides  of  the  latter  and  seem  to  prefer  the  region  of  the  fingernails. 
In  rare  instances,  melanomata  develop  from  the  mucosa  of  the  nose, 
the  soft  palate,  and  the  rectum.  Primary  invasion  of  the  pia  and 
arachnoid  membranes  is  questioned,  on  the  ground  that  secondary 
nodules  may  develop  in  this  situation  many  years  after  the  removal 


Fig.  581. —  Primary  MELAi;oiiA 
OF  THE  Heel. 

(Symmers,  Bellevue  Hospital 
case). 


1202 


TUMORS 


of  a  melanotic  eyeball  and,  unless  a  corroborative  history  is  obtained, 
may  be  regarded  as  primary  (Dobberlin*-). 

Melanotic  tumors  consist  of  cellular  elements,  which  contain  the 
coloring  matter.  Not  until  the  cells  disintegrate  is  the  latter  found 
outside  of  them.  Ribbert^  holds  that  the  color  is  contained  in  a 
special  class  of  pigmented  connective  tissue  cells,  or  cJiromatophores, 
hence  the  name  chromatophoroma. 

The  pigment  cells  contained  in  melanomata  of  the  orbital  bulb 
show  the  least  deviation  from,  the  normal,  as  they  exist  in  the  choroid, 
the  iris,  in  pigmented  skin  areas,  such  as  the  areola  around  the  nipple, 
in  the  arms,  and  the  congenital  nevi.  In  the  eyeball,  as  long  as  the 
process  is  in  its  early 
stages,  the  cells  resemble 
elongated  hands  that 
gradually  terminate  in 
slender  jilaments;  they  lie 
closely  apposed  to  one 
another  and,  on  section, 
present  an  appearance 
not  unlike  that  of  spindle 
.cell  sarcoma.  When,  how- 
ever, the  process  per- 
forates the  eyeball,  its 
structure  takes  on  the 
character  usually  found 
in  skin  melanomata  (Rib- 
bert^).  At  this  stage,  the 
presence  o  f  chromato- 
phores  can  be  recognized 

only  in  fresh  preparations  (Ribbert^).  The  other  elements  com- 
posing the  tumor  vary  greatly.  They  consist  in  round  and  spindle 
cells,  between  which  a  number  of  atypical  cells  with  short  pro- 
jections, and  with  or  without  coloring  matter,  may  be  found.  Ribbert^ 
considers  these  as  representing  various  stages  of  undeveloped  cellular 
elements.  Those  without  pigment  he  regards  as  young  cells ;  the  large 
round  tj^pe,  rich  in  pigmented  deposits,  as  mature  and  readj'^  to  disin- 
tegrate; and  the  others  he  believes  to  be  in  the  stage  of  predevelop- 
ment.  Not  seldom  a  section  reveals  the  presence  of  epithelium-like 
polymorphous  and  round  cells  within  a  fibrillary  network  presenting 
an  alveolar  arrangem-ent.    The  fibrillary  structure  containing  the  blood 


Fig.  582. —  Melanoma  of  the  Skin. 


SARCOMATA  1203 

vessels  is  not  sharply  defined  against  the  cells  and  is  bordered  by 
heavily  pigmented  cells,  the  color  of  which  is  the  more  accentuated, 
as  the  cells  lying  within  the  alveoli  are  usually  free  from  color  and 
are  only  pigmented  when  the  tumor  is  particularly  deeply  colored. 
Fine  fibrillae  form  bundles  that  pass  between  the  different  cells.  Rib- 
bert^  regards  these  fibers  as  important  in  the  sense  that,  if  they  arise 
from  the  connective  tissue,  it  argues  against  the  origin  of  melanomata 
from  the  pigmented  cells  of  the  skin  and  retina.  The  discussion  of 
the  origin  of  chromatophores  has  not  led  to  elucidation.  The  prob- 
lem is  taken  up  in  extensio  by  Borst^  and  Ribbert.^ 

The  pigment  called  melanin  is  a  granular  or  lumpy  brown  mass  con- 
tained within  the  cell  protoplasm  and  is  regarded  as  the  product  of  the 
latter.  It  usually  lies  at  the  periphery  of  the  cell  and,  when  the  tumor 
disintegrates,  is  taken  up  by  invading  cells  and  carried  to  other  por- 
tions of  the  tumor  (Borst^) .  It  contains  no  iron,  but  is  rich  in  sulphur. 
The  alveolar  structure  of  many  melanomata  of  the  skin,  and  the 
presence  of  large  pigmented  cells  within  the  tumor  stroma,  are  sug- 
gestive of  carcinoma.  As,  however,  the  cells  from  which  the  lesion 
originates  (the  chromatophores),  like  the  lymph  corpuscles,  represent 
a  special  form  of  connective  tissue  cell,  melanomata  must  he  classed 
with  the  sarcomata  (Ribbert^).  However,  the  occasional  presence  of 
epithelial  pearls  shows  that  there  is  such  a  thing  as  a  genuine  melan- 
otic carcinoma  (Borst^). 

The  origin  of  melanomata  is  not  clearly  understood.  The  presence 
of  displaced  groups  of  pigment  cells  in  the  eye,  associated  with  tumors 
of  the  sclera,  justifies  the  assumption  that  tumors  may  arise  from 
nuclei  of  this  sort  and  explains  the  occurrence  of  melanoma  in  the 
fatty  tissue  of  the  orbit.  It  is  also  important  that  the  vast  majority 
of  skin  melanomata  develop  at  the  site  of  congenital  nevi  which  seems 
to  establish  a  connection  between  the  cells  of  melanomata  and  those 
of  the  nevi.  The  fact  that  nevi  contain  pigmented  cells  in  the  ground- 
work of  their  epidermis  and  fully  developed  chromatophores  in  the 
corium  of  the  warty  form,  together  with  especially  dense  columns  of 
round  and  oval  cells  that  are  not  pigmented,  permits  of  elasticity  in 
conception  as  to  which  structure  is  responsible  for  melanoma.  While 
the  so-called  nevus  cells  have  been  regarded  as  epithelial  and  endothe- 
lial cells  of  the  lymph  spaces,  and  as  connective  tissue  cells  derived 
from  the  cuticular  nerve  fibers,  Ribbert^  insists  that  they  are  geneti- 
cally identical,  but  badly  differentiated  chromatophores  (without  pig- 
ment). 


1204 


TUMORS 


The  precise  manner  in  which  melanoma  is  developed  from  a  nevus 
is  not  clear.  Ribbert^  considers  that  they  spring  only  from  fully  de- 
veloped chromatophores ;  others  attach  importance  to  proliferation  of 
the  groups  of  nevus  cells.  Krompecher"  believes  that  they  develop 
from  the  basal  cells  of  the  epidermis,  which  he  regards  as  also  re- 
sponsible for  the  nevus  cells. 

Virchow^*  states  that  the  fact  that  M'hite  horses  (especialh'  those  born 
colored)  are  particularly  likely  to  develop  melanoma  is  explainable  on 
the  ground  of  the  activity  of  the  pigmentation  process,  and  thus  irregu- 


J 

mjm 

tM^    - — 

i 

^1^ 

yj 

l^\ 

'  '  w  Hrf^ 

m 

iw 

^i  ^ 

,'^\^;:\^ 

.    <S 

-m 

} 

•• 

*^'mtl 

'^%. 

¥ 

i  i 

^\4 

•■1 

'1 

1 

k^Tft 

$' ^ 

w 

( 

WT 

m  '-m^ 

MM 

• 

Hb  h^ 

'mw 

Pig.  583. —  Metastatic  Melanoma  in  ITpper  Tibia. 


larities  in  this  connection  occur.  A  clear  elucidation  of  the  problem 
is  thus  far  not  available. 

The  growth  of  melanoma  is  alwa.ys  infiltrating  in  character,  the 
cells  invading  all  the  tissue  spaces.  The  lymph  and  blood  vessels  are 
especially  involved  and  over  extensive  areas. 

Extension  hy  the  lymph  vessels  occurs,  at  first,  in  the  immediate 
vicinity  of  the  primary  lesion  in  the  form  of  small  secondary  nodules. 
These  are  often  uncovered  in  the  subcutaneous  tissues  during  extirpa- 
tion of  a  melanoma  of  the  skin.  They  frequently  reveal  the  extent 
to  which  the  process  has  pursued  its  unobserved  course.  Gradually 
the  lesion  extends  to  more  distantly  located  lym'ph  nodes,  which  soon 


SARCOMATA 


1205 


assume  the  form  of  large  nodular  masses.  In  primary  melanoma  of 
the  eyeball,  the  first  metastatic  nodules  usually  make  their  appearance 
in  the  brain. 

The  proliferation  of  melanoma  cells  into  the  Mood  vessels  is  fol- 
lowed b}'  massive  invasion  of  the  blood  current.  This  is,  at  times,  so 
active  that  the  pigmented  tumor  cells  may  be  found  in  the  capillaries 
and  larger  vessels  of  the  vital  organs,  such  as  the  liver.  This  accounts 
for  the  extraordinary  jnultiplicitij  of  metastases,  which  do  not  appear 
in  a  single  organ  but  simultaneously  invade  a  number  of  them  (lung, 


Fig.  584. —  Xevus  Pigmentoscs  Pii.osrs. 

liver,  spleeu,  brain,  gut,  serous  membranes,  bone  marrow).  At  the 
same  time  the  skin  and  mucous  membranes  are  extensiveh'  discolored 
{mela^iosis) . 

The  pigmented  content  of  the  metastatic  nodules  A'aries  widely; 
some  contain  dark,  black  foci,  while  others  are  entirely  free  from 
coloring  matter.  The  rapidity  of  the  proliferation  probably  explains 
the  deficiency  in  the  development  of  pigment  cells. 

The  disintegration  of  portions  of  a  tumor  liberates  free  pigment, 
which  gains  access  to  the  blood,  is  deposited  in  the  organs,  and  may  be 
eliminated  in  the  urine  (melamiria). 


1206 


TUMORS 


The  clinical  course  of  melanoma  corresponds  to  its  rapid  growth  and 
dissemination  throughout  the  body.  When  the  growth  is  not  extir- 
pated, an  early,  fatal  outcome  occurs  (from  anemia,  destruction  of 
organs  by  metastases,  general  infection  when-  the  tumors  necrose  and 
ulcerate).  Extirpation  is  usually  followed  by  recurrence,  and,  when 
this  occurs  early,  it  is  probable  that  unrecognized  metastases  existed 
at  the  time  of  the  operation.  At  times  the  fatal  outcome  may  be 
postponed  by  operative  efforts.  Permanent  relief  can  be  afforded  only 
by  early  removal  of  the  growth. 


Fig.  585. —  Nevus  Pigmentosus  Verruco.-i  s. 

The  diagnosis  is  attended  with  difficulty  only  in  the  early  stages  of 
the  process,  though  the  rapid  growth  of  the  lesion  leaves  at  no  time  any 
doubt  as  to  its  malignant  character.  Vascular  sarcomata  with  exten- 
sive hemorrhagic  areas  are,  at  times,  dark  in  color  and  may  resemble 
melanomata,  especially  when  the  growth  is  sectioned  for  diagnostic 
purposes  during  an  operation.  In  these  cases  the  assistance  of  the 
microscope  is  necessary. 

The  treatment,  in  view  of  the  great  malignancy  of  the  process,  con- 
sists in  early,  complete  removal  of  the  lesion,  together  with  as  wide  a 
sector  of  contiguous  tissue  as  is  possible.     When  the  neareit  lymph 


SARCOMATA 


1207 


nodes  are  involved,  surgical  efforts  at  relief  are  not  likely  to  be 
successful. 

In  melanoma  of  the  eyeball, 
even  though  the  process  is  intra- 
opthahnic,  the  entire  contents  of 
the  orbital  cavity  sho-uld  be  ex- 
cised. When  a  skin  lesion  is 
located  on  an  extremit}',  high 
amputation  is  justifiable. 

As  pigmented  moles  and  nevi 
are  frequently  the  precursors  of 
melanomata,  they  are  described 
with  them,  although  the  classifi- 
cation of  pigmented  nevi  is  a 
much  contested  subject.  V. 
Recklinghausen^"'  and  Ziegler^" 
classify  them  with  lymphangio- 
mata;  Unna  and  others  wnth  the 
epithelial  tumors;  Borst^  re- 
gards them  as  melanotic  fibro- 
mata. 

Pigmented  nevi  appear  in 
various  forms,  which  may  merge 
into  one  another. 

Flat  nevi  {nevi  spili)  are  cof- 
fee brown,  or  eve  n  darker, 
colorations  of  the  skin,  varying 
in  size  from  that  of  a  piuhead  to 
that  of  a  saucer.  They  have 
sharply  defined  bodies,  are  level 
with  the  skin,  and  resemble  in 
appearance  and  are  histologi- 
call}^  identical  with  lentigenes 
or  freckles.  The  lesions  are 
often  distributed  over  the  entire 

bodv  and  frequently  coexist  with 
Fig.  586.— a  Young  Woman   Eigh-  '  .  "^ 

TEEN  Years  of  Age  with  Multi-  nerve  elephantiasis. 

PLE  Nevi  and  an  Elevated,  Hairy  Elevated    nevi    (nevi    promi- 

Verrucous  Nevus,  WHICH  Involves  ^^      ^     ^  ^        • 

the  Left  Cheek,  Scalp,  and  Neck.  nentes)   are  usually  darkly  pig- 


1208 


TUMORS 


mented,  beet-like,  soft  growths  which  often  extend  over  large  areas  of 
the  bod}'-.  Their  surface  is  either  smooth  and  glistening  and  slightly 
fissured,  or  deeply"  furrowed  and  covered  tvith  hair  and  warty  excres- 
cences. The  elevated  form  is  further  subdivided  into  hairy  nevi  {nevi 
pilosi,  Fig.  584),  which  are  thickly  covered  with  short,  dark,  coarse  or 
soft  hair  growing  from  a  dark  ground;  and  the  warty  nevi  (nevi  ver- 
rucosi,  papillomatosis)  which  are  covered  with  warty  growths  (Fig. 
585).  These  are  either  small,  soft  or  corneous,  round  or  pedunculated 
nodules,  or  deeply  furrowed  and  covered  with  thorny  papillae.  The 
papillomatous  proliferation  often  appears  later  on  the  nevus. 

Pigmented  nevi  are  congenital  or  appear  soon  after  birth,  after 
which  the}'  grow  slowly,  reach  a 
certain  size,  an(i  then  become  sta- 
tionary.     Only    the   warty    form 
appears  late  in  life. 

They  appear  upon  the  skiji  of 
any  portion  of  the  bod}'  and  are 
often  multiple  (Fig.  586). 

In  many  cases,  nevi  develop  in 
the  course  and  zone  of  distribu- 
tion of  the  skin  nerves  of  one  side 
of  the  body,  or  appear  sj-mmetri- 
cally  .on  both  sides  {nerve  nevi), 
especially  on  the  face  and  neck 
At  times  they  develop  on  the  skin, 
covering  plexiform  neuromata  or 
superficial      nerve      fihromata. 

Again,  the  flat  form  appears,  together  with  soft  warts  and  skin  fibro- 
mata, over  the  entire  skin  of  the  bod}' ;  they  are  not  uncommonly  asso- 
ciated with  so-called  v.  Recklinghausen's  disease. 

All  of  these  considerations  seem  to  indicate  that  nevi  bear  some  re- 
lation to  nerve  fibromatosis,  though  the  connection  is  not  clear.  Sol- 
dan*®  regards  rievi  as  fibromata  of  the  smaller  cutaneous  nerve  fila- 
ments and,  although  this  view  is  not  proved,  it  throws  a  shimmer  of 
light  into  the  prevailing  darkness  (Lexer*^). 

Histologically  (Figs.  587-588),  the  elevated  nevi  consist  of  connec- 
tive tissue  proliferation  of  the  cutis,  especially  the  papillary  bodies 
which  merge  into  the  subcutaneous  tissue.  In  this  proliferation,  the 
epidermis  is  concerned  to  a  varying  degree  so  that  the  structure  of  the 
pigmented  nevus  resembles  fibro-epithelial  new  growth. 


Fig.  587. 


Small  Pigmented  Nevus 
OF  THE  Skin. 


SARCOMATA 


1209 


The  pigment,  in  the  form  of  a  fine,  granular  mass,  is  located  in  the 
cylindrical  cells  of  the  stratum  germinativum  of  the  epidermis,  and 
in  the  large  chr o mat oph ores  of  the  corium.  In  addition  to  this,  collec- 
tions of  round  or  oval  cells,  the  so-called  nevus  cell  rests,  are  found 
in  the  proliferated  cuticular  connective  tissue  and  these,  together  with 
the  pigmented  cells,  form  the  main  cellular  elements  of  the  various 
forms  of  nevi.  V.  Recklinghausen,*'*  Ziegler*'^  and  Borst^  regard  these 
as  proliferated  endothelial  cells  of  the  lymph  vessels;  Ribbert^  con- 
siders them  imperfectly  differentiated  chromatophores  embedded  in  a 
fine  net  work  of  fibrillae;  Soldan"*"  believes  them  to  be  connective  tissue 

cells  derived  from  nerve 
filaments ;  Unna*^  and 
his  school,  and  March- 
and  and  Orth"°  contend 
that  they  are  of  epithe- 
lial origin,  and  Krom- 
pecher^^  holds  that  they 
are  proliferated  basal 
cells  of  the  epidermis. 
Gilchrist"*^  supports  the 
theory  of  their  epithelial 
origin.  The  groups  of 
cells  often  occur  in 
columns  or  radiate  to- 
ward the  surface  and 
are  more  numerous  in 
the  deeper  layers  of  the 
epidermis,  to  the  cells  of 
which  they  are  closely 
apposed. 
The  diagnosis  of  nevi  is  readily  made  by  their  appearance.  When 
they  are  prominently  protruded,  the  presence  of  underljang  plexi- 
form  neuromata  ma^'  be  assumed. 

The  removal  of  nevi  is  indicated  for  cosmetic  reasons,  especially 
when  they  are  located  on  the  face  or  the  neck.  For  the  purpose,  the 
growth,  together  with  the  subjacent  subcutaneous  tissue,  is  excised. 
When  the  residual  defect  is  large,  it  should  be  repaired  hy  transplan- 
tation of  skin,  as  the  use  of  pedunculated  flaps  from  the  contiguous 
areas  is  followed  by  deforming  cicatrization.  Epidermal  flaps  also 
leave  disfiguring  scars.     A  free  dermal  transplant  gives  satisfactory  re- 


FiG.  588. —  Flat  Pigment  Nevus. 

Chromatophores   in    the   connective   tissue   and 
beneath  the  eiiidermis. 


1210  TUMORS 

suits.  In  multiple  nevi  operative  efforts  at  relief  should  be  limited  to 
those  situated  on  the  face  and  neck.  As  every  nevus  is  potentially  a 
malignant  growth  (melanoma),  its  removal  should  be  accomplished,  if 
feasible.  The  appearance  of  a  nodule  in  the  growth  heralds  the  advent 
of  malignancy  and  is  an  indication  for  immediate  radical  excision. 

Xanthoma,  or  xanthelasma,  is  a  term  applied  to  a  growth  of  the 
skin  which  appears  in  the  form  of  small,  yellow  or  brownish,  circum- 
scribed spots  {xanthoma  planum)  and  nodular  elevations  {xanthoma 
tuberosum) .  The  process  appears  most  often  on  the  skin  of  the  eye- 
lids, but  may  appear  in  other  situations,  such  as  the  mucous  mem- 
branes of  the  respiratory  passages,  the  mouth,  and  the  esophagus.  It 
is  often  multiple;  is  occasionally  congenital  or  hereditary ;  and  is 
peculiar  to  advanced  life. 

The  proliferation  also  contains  nests  of  cells  which  resemble  those 
found  in  nevi.  Unlike  the  latter  they  contain  granular,  yellow  pigment 
and  fat  globules  resembling  the  cells  of  proliferating  fatty  tissue 
(Borst^). 

BIBLIOGRAPHY 

1.  BORST.     Die  Lehre  der  Geschwlilste,  Wiesbaden,  1902,  -with  lit. 

2.  MacCallum.     Text  Book  of  Path.,  Pbila.,  1916. 

3.  RiBBERT.     Geschwiilstlehre,     Bonn,    1904;     also    Beitr.    z.    Ensteh.     d. 

Geschwiilste,  Bonn,  1906. 

4.  BoRST.     Cong.  Inteniat.  de  Med.,  Lisbonne,  1906,  see.  iii.    • 

5.  Alberti.     Quoted  by  Hazen,  Jr.  Cut.  Dis.,  1911,  xxix. 

6.  TiLDEN.     Boston  Med.  and  Surg.  Jr.,  1885,  cxiii. 

7.  Unna.     Histopathologie  d.  Hautkrankbeiten,  Berlin,  1894. 

8.  WoLTERS.     Biblioth.  med.  Abt.  D.  ii,  H.  7,  1899. 

9.  Nasse.     Virchow's  Arcb.  Bd.  94,  1883. 

10.  V.  Mikulicz.     Cbir.  Kong.  Verb.,  1895,  ii. 

11.  KOENiG.     Discussion  of  v.  ]\Iikulicz's  report,  see  No.  10. 

12.  Reinhardt.     Deutscb.  Zeitscbr.  f.  Cbir.,  Bd.  47,  1898. 

13.  HODGKixs.     Quoted  by  Ziegler  No.  18. 

14.  Billroth.     Quoted  by  Ziegler  No.  18. 

15.  CoHNHEiM.     Quoted  by  Ziegler  No.  18. 

16.  Orth.     Quoted  by  Ziegler  No.  18. 

17.  CONAN.     Arcb.  f.  klin.  Cbir.  Bd.  73,  1904. 

18.  K.  Ziegler.     Hodgkin'scbe  Krank,  Jena,  1911. 

19.  Sternberg.     Zentrbl.  f.  d.  Grenzgeb,  1899,  with  lit. 

20.  OsKAR  Meyer.     Frankfurter  Zeitscbr.  f.  Patb.  Bd.  8,  1911. 

21.  Dietrich.     Beitr.  z.  klin.  Cbir.,  Bd.  91,  1910. 

22.  Fraenkel  und  Much.     Verb.  d.  Path.  Gesellscb.,  1912. 

23.  White.     Jr.  A.  M.  A.  xlxix,  1907. 

24.  Billroth.     See  Sternberg  No.  19. 

25.  CzERNEY.     See  v.  Winiwarter  No.  26. 

26.  V.  Winiwarter.     Arch.  f.  klin.  Cbir.  Bd.,  1875. 


SARCOMATA  1211 

27.  V.  ZiEMSSEN.     See  K.  Ziegler  No.  18. 

28.  Hoffmann.     Arch.  f.  kliu.  Chir.,  Bd.  79,  1906. 

29.  Permin.     Virchow's  Arch.,  Bd.  189,  1907. 

30.  V.  Verebely.    Beitr.  z.  klin.  Chir.,  Bd.  43,  1906. 

31.  Yellinek.     Virchow's  Arcli.,  Bd.  177,  1904. 

32.  Winkler.     Virchow's  Arcli.,  Bd.  161,  1900. 

33.  WiELAND.     Virchow's  Arch.,  Bd.  106,  1901. 

34.  V.  Recklinghausen.     Quoted  by   Steniberg  in  Ziegler's  Beitr.,  1904, 

xxxvii. 

35.  Chiari.     Quoted  by  Sternberg  in  Ziegler's  Beitr.,  1904,  xxxvii. 

36.  Huber.     Quoted  by  Sternberg  in  Ziegler's  Beitr.,  1904,  xxxvii. 

37.  Meixner.     Wiener  klin.  Woch.,  1907, 

38.  Roman.     Zeigler's  Beitr.,  1913,  Iv,  61  (with  lit.). 

39.  Zahn.     Deuitsch.  Zeitschr.  f.  Chir.,  Bd.  22,  1885. 

40.  V.  WiNCKEL.     Samml.  klin.  Vort.  No.  140,  1895. 

41.  Jacobsthal.     Virchow's  Arch.  Bd.  159,  1900,  with  lit. 

42.  DOBBERLIN.     Beitr.  z.  path.  anat.  Bd.  28,  1900. 

43.  Krompecher.     Der  Basalzellenkrebs,  Jen-a,  1903,  with  lit. 

44.  ViRCHOW.     Quoted  by  Krompecher  No.  43. 

45.  V.  Recklinghausen.     See  Roman  No.  38. 
40.  Ziegler.     See  Roman  No.  38. 

47.  Unna.     Berlin,  klin.  Woch.,  1893. 

48.  Lexer.     Allgem.  Chir.  ii,  Stutts-ai-t,  1914, 

49.  SOLDAN.     Arch.  f.  klin.  Chir.  Bd.  59,  1899. 

50.  Marchand  and  Orth.     Quoted  by  dalla  Farera,  Ziegler's  Beitr.,  3903, 

xliii. 

51.  Gilchrist.     Jr.  Cut.  and  G.  U.  Dis.,  1899,  xvii. 


CHAPTER  XII 


TUMORS  COMPOSED  OF  MUSCLE 


Leiomyomata  {Leiomyoma  levicellulare) . —  Leiomyomata  {myoma 
levicellulare)  are  essentially  henign  tumors  and  are  usually  encapsu- 
lated, rarel}"  in  filtrating,  and  equally"  rarely  form  metastases.  They 
occur  as  round,  smooth  or  nodular  masses  in  the  uterus  and  in  the 
skin,  where  thej^  are  often  multiple,  grow  very  slowly,  and,  at  times, 
in  the  uterus  or  gut  at'ain  the  size  of  an  adult  head.  On  section, 
the  macroscopic  picture  pre- 
sents a  grayish  red  surface, 
in  which  large  bundles  of 
fibers  are  plainly  visible. 

Histologically,  leiomyo- 
in  the  mounted  specimen, 
mata  are  composed  of 
smooth  muscle  fibers  which. 
are  seen  to  run  in  all  direc- 
tions (Fig.  589).  The  muscle 
fibers  have  blunt,  rounded 
ends  and  are  easily  differ- 
entiated from  the  tapering- 
connective  tissue  fiber  of 
fibromata.  The  former  are 
bound  together  by  a  fibrous 
tissue    which    contains    the         Fig.  .389.- Leiomyoma  of  the  Uterus 

fl.    Transverse    section   of   bundle   oi    muscle 
blood  vessels.     The  edge  of   fibers. 

the  tumor  is  inclosed  in  a 

thin  capsule,  or  its  meshes  merge  into  the  surrounding  tissues,  with 

which  they  are  intimately  associated. 

A  sparsity  of  interstitial  tissue  gives  the  growth  a  soft  consistence; 
when,  however,  connective  tissue  predominates  it  is  hard  {fibro- 
myoma) .  A  certain  number  of  tumors  are  exceedingly  vascular  {fibro- 
myoma  telangiectaticum) .     Malignant  myomata  are  rich  in  cellular 

1212 


TUMORS  COMPOSED  OF  MUSCLE  1213 

elements  and  bear  a  strong  resemblance  to  spindle  cell  sarcoma.  These 
gTow  very  rapidly,  infiltrate  the  surrounding  tissues,  and  form  metas- 
tases. AVhether  genuine  sarcoma  develops  in  place  of  the  interstitial 
tissue,  i.  e.,  a-  mixed  tumor  consisting  of  sarcomatous  and  myomatous 
tissue  {leiomyosarcoma) ,  or  whether  the  process  is  one  of  muscle  cell 
proliferation  in  which  the  nuclei  are  converted  into  the  long  oval 
shape  common  to  spindle  cell  sarcoma,  is  not  clear  (Ribbert^)  ;  how- 
ever, when  the  structure  of  sarcoma  tissue  is  clearly  defined  against 
the  muscle  cells,  the  tumor  may  be  regarded  as  a  sarcoma  developed 
within  a  mj'oma. 

Large  leiomyomata  are  likely  to  undergo  regressive  changes  attri- 
butable to  insufficient  vascular  suppl}'.  These  take  the  form  of  hollaw 
spaces  filled  with  detritus,  areas  of  fatty  and  hyalin  degeneration  and 
of  calcification,  and,  in  pedunculated  myomata,  consist  in  edematous 
saturation  from  twisting  or  kinking  of  the  pedicle. 

Concerning  the  genesis  of  leiomyomata,  the  not  infrequent  pres- 
ence of  muscle  fihers  derived  from  hlood  vessels  is  important.  To  this 
may  be  added  the  occasional  discovery  of  glandular  elements  in  tumors 
of  this  sort  in  the  uterus  and  in  the  stomach;  factors  suggesting  that 
not  only  the  adenamyoma,  but  also  a  certain  number  of  pure  myomata 
are  the  outcome  of  developmental  anomalies  in  which  a  sector  of 
muscle  fibers  has  teen  displa-ced  in  early  life,  and  later  assumes  inde- 
pendent growth. 

Leiomyomata  are  most  often  situated  in  the  uterus,  where  they  usu- 
ally grow  from  the  fundus  in  large  numbers.  They  may  be  located  on 
the  outer  (subserous)  or  on  the  inner  (suhmucous)  surface,  or  Avithin 
the  substance  {intramural)  of  the  uterus,  where  they  are  either 
round  or  oval,  sharply  defined,  and  of  firm  consistence.  In  this  situ- 
ation the  growth  i^  usually  benign.  The  ligaments  and  the  fallopian 
tubes  are  o-ften  invaded. 

The  presence  of  uteromyomata  of  epittielial,  glandular  tubules,  and 
of  hollow  spaces  lined  with  cubical,  cylindrical,'  and  ciliated  cells,  has 
been  demonstrated  by  v.  Recklinghausen-.  Growths  of  this  sort  are 
called  adenomyomata;  they  are  usually  subserous  and  are  located  op 
the  posterior  surface  of  the  uterus,  in  the  corn<ua  and  between  the 
layers  of  the  broad  ligaments,  where  they  appear  as  small,  not  clearly 
defined,  tumors.  They  are  believed  to  originate  in  part  from  displaced 
mucuous  glands,  and  in  part  from  the  wolffian  bodies  or  ducts,  or 
from  mliller's  duct,  and  are  probably  displaced  simultaneoush'  with 
the  epithelial  and  muscle  tissue. 


1214 


TUMORS 


Leiomyomata  are,  at  times,  found  in  the  g astro-intestinal  tract,  where 
they  arise  from  the  musculature.  They  appear  in  the  esophagus  as 
small  nodular  masses,  but  in  the  stomach,  the  small  gut,  the  colon  and 
the  rectum,  they  often  attain  large  proportions  (Fig.  590),  extend  in- 
ward or  outward,  and  are  attached  by  a  broad  base  or  pedunculated. 
In  some  instances  they  are  multiple.     The  discovery  of  a  pancreatic 


Fig.    590. —  FiBROMYOMA    OF   THE    POSTERIOR   WALL    OF    THE    EeCTUM    REMOVED    BY 

Eesection  of  THE  RECTUM  (Male  Patient  Thirty-five  Years  of  Age). 


tissue  in  a  myoma  of  the  stomach  b}^  Cohen^  adds  support  to  the  notion 
that  growths  of  this  nature  are  congenital  in  origin.  Malignant  my- 
omata  in  this  situation  are  rare. 

In  the  urinary  tract,  myomata  do  not  often  make  their  appearance, 
though  they  occur  occasionally  in  the  bladder.  Lexer*  reports  a 
case  of  a  large  malignant  myoma  emanating  from  the  superior  pos- 
terior wall  of  the  Madder.  Biittner^  found  a  large  myoma  attached 
to  the  urethra,  and  Nicolau*'  one  the  size  of  a  bean  arising  from  the 
glans.  The  kidney  is  at  times  the  seat  of  small  leiomyomata  that  are 
connected  with  its  capsule. 


TUMORS  COMPOSED  OF  MUSCLE  1215 

The  prostate  is  rarely  the  seat  of  a  pure  myoma,  its  hypertrophy 
usually  involving  its  entire  structure  or  that  of  a  sector  which  is  at- 
tended with  increase  in  its  entire  size. 

Leiomyoma ta  also  occur  in  the  mammae  and  in  the  testicle. 

In  the  skin,  myomata  are  most  often  multiple,  and  appear  in  the 
form  of  small  (size  of  hazel  nut)  nodules  on  the  trunk  and  extremi- 
ties where  they  are  covered  by  normal  skin,  are  elevated  above  the 
surface,  and  are  likely  to  be  very  painful.  They  originate  either  from 
the  muscle  fibers  of  the  Mood  vessels  or  from  the  hair  follicles.  Clini- 
cally, they  cannot  be  separated  from  fibromata  of  the  nerves. 

The  diagnosis  of  leiomyomata  is  easy  only  when  they  are  located  in 
the  uterus.  Their  occurrence  in  other  situations  is  so  rare  that  a  slow 
growing  tumor,  possessed  of  the  characteristics  stated,  would  most 
likely  be  regarded  as  a  fibroma  or  as  an  encapsulated  sarcoma.  A 
large  pedunculated  mass  attached  to  the  stomach  or  gut  or  bladder 
might  suggest  the  possibility  of  a  myoma.  The  pain  that  attends  the 
skin  lesions  would  most  likely  make  the  surgeon  think  of  nerve  fibro- 
mata, unless  pigmented  warts,  which  are  so  often  the  companions  of 
nerve  tumors,  were  absent. 

The  treatment  consists  of  extirpation.  When  the  tumors  encroach 
seriously  upon  the  invaded  organ  (as  frequently  obtains  in  the  uterus), 
the  latter  must  be  sacrifieed.  Encapsulated  tumors  may  be  readily 
enucleated;  when  the  fibers  of  the  lesion  merge  with  the  surrounding 
tissues,  a  portion  of  the  latter  must  also  be  excised. 

BIBLIOGRAPHY 

1.  RiBBERT.     Gescliwiilstlehre,     Bonn,     1904;     also     Beitr.     z.     Ensteh.     d. 

Geseliwiilste,  Bonn,  1906. 

2.  V.  Recklinghausen.     Adenomyoma  of  the  Uterus,  Berlin,  1896. 

3.  Cohen.     Virchow's  Arch,  elviii,  1899. 

4.  Lexer.     Zentrhl.  f.  Chir.,  1904. 

5.  BiJTTNER.     Zeitschr.  f.  Geburtshilfe,  xxviii,  1894. 

6.  NicoLAU.    Zentrbl.  f.  Chir.,  1910. 


CHAPTER  XIII 
EHABDOMYOMATA 

Rhabdomyoma  {myoma  striocellular)  is  a  rare,  at  times  benign, 
and,  at  others,  ynaligna^U,  tumor  composed  of  striated  musculature  and 
connective  tissue  fibers,  the  latter  containing  the  blood  vessels.  They 
rarely  consist  of  muscle  fibers  alone,  and  have  much  in  common  with 
ynixed  tumors. 

Macroscopicalhj ,  the  growth  is  nodular  in  form,  usually  sharply  de- 
fined, and  may  reach  large  dimensions.     On  section,  it  is  found  to 


|lllVil';!^^Vi 


Fig.  591. —  Rhabdomyoma  of  the  Temporal  Kegion. 

b,  b,  Muscle  cells  cut  parallel  to  their  long  axes,  in  which  fusiform  enlarge- 
ments and  transverse  striations  may  be  seen,  g,  g,  Round  cells  with  processes; 
h,  round  cell  without  processes.  The  dark  deposits  represent  drops  of  glycogen 
(from  Ribbert). 

consist  of  grayish  red  tissue,  the  fibers  of  which  are  not  as  clearly 
visible  as  those  of  leiomyomata. 

Microscopically  (Fig.  591),  it  is  seen  that  the  muscle  fibers  are  not 
fully  developed,  but  are  in  embryoyiic  form  in  various  stages  of  de- 
velopment and  appear  in  the  form  of  cells  and  fibers.  Tlie  latter  are 
found  to  be  hollow  tubules  or  solid  multinuclear  bands  of  consider- 
able length  and  varying  thickness,  with  clearly  marked  transverse  or 

1216 


RHABDOMYOMATA  1217 

longitudinal  striations.  The  cellular  portion  develops  as  a  spindle  cell 
with  long,  slender  processes,  presenting  few  striations,  or  as  oval  or 
round  uni-  or  multinuclear  cells.  Both  forms  of  the  cell  often  con- 
tain glycogen  globules  (Marchand^).  The  latter  readily  respond  to 
the  iodin  test.  The  striated  fibers  are  encased  in  a  very  delicate 
sarcolemma. 

The  structure  of  rhabdomyomata  varies  in  different  growths;  at 
times,  cellular  elements  predominate,  at  others,  the  fibers  are  the  more 
abundant.  The  more  the  fibers  and  cells  are  grouped  and  interlaced, 
the  greater  resemblance  does  the  tumor  bear  to  leiomyoma  or  fibroma. 

In  considering  the  origin  of  rliahdomyomata,  it  must  be  remembered 
that  many  mixed  tumors  which  are  ascribable  to  developmental  ano- 
malies with  certainty  contain  muscle  elements,  and  that  these  (the 
muscle  elements)  exist  in  pure  myomata  only  in  embryonic  form.  As 
rlmbdomyomata  are  either  congenital  or  make  their  appearance  early 
in  child  life,  and  as  they  develop  in  organs  that  normally  do  not  con- 
tain striated  muscle  tissue,  it  is  justifiable  to  believe  that  tumors  of 

THIS  SORT  ORIGINATE  FROM  GERMINAL  MUSCLE  TISSUE  WHICH,  DURINGf- 
EARLY  EMBRYONIC  LIFE,  WAS  SEPARATED  FROM  ITS  PROPER  PHYSIOLOGICAL 

ENVIRONMENT  (Ribbcrt^).  The  possibility  of  the  conversion  of  smooth 
into  striated  muscle  fiber,  and  the  tumorous  proliferation  of  normal, 
fully  developed  musculature,  have  also  been  taken  into  account ;  how- 
ever, neither  of  these  finds  suport  in  the  discernible  facts  (Ribbert"). 

Rhabdomyomata  are  most  often  resident  in  the  kidney,  where  they 
arise  froml  within  its  interior  and  gradually  destroy  its  structure.  In 
this  situation  they  often  reach  great  size  and  extend  into  the  kidney 
pelvis  in  the  form  of  nodular  and  polypoid  protrusions.  In  some  in- 
stances they  originate  from  the  pelvis  of  the  kidney,  the  bladder  and 
the  testicle.  They  are  also  found  in  the  uterus  and  the  heart.  In  the 
former  situation  they  usually  take  the  form  of  polypi  that  extend  into 
the  vagina,  though  they  may  also  begin  in  the  vagina  and  extend  into 
the  bladder  (Fig.  592).  In  the  heart  the  process  is  congenital  and  is 
restricted  to  the  formation  of  small,  grayish  red  nodules.  Single 
tumors  have  been  found  in  the  esophagus,  the  stomach,  the  parotid 
gland,  the  prostate,  and  the  muscles  of  the  extremities ;  also  in  the 
region  of  the  nates,  the  hips,  the  orbit,  the  temporal  region,  etc. 

In  the  growth  of  rhabdomyomata,  the  young,  spindle  and  round  cell 
elements  are  first  formed,  and  these  are  later  converted  into  striated 
muscle  fibers.  The  tumor  increases,  at  first  by  slow  expansion,  but 
later,  the  process  becomes  infiltrating  in  character,  grows  rapidly,  and 


1218 


TUMORS 


causes  the  formation  of  metastases.  At  this  writing,  it  is  not  clear 
whether  this  means  that  the  rhabdomyoma  itself  develops  a  malignant 
character,  or  that  the  admixture  of  conyiective  tissue  sarcoma  has  oc- 
curred.    In  mixed  tumors,  the  latter  is  undoubtedly  the  case;  on  the 


Fig.  592. —  Grape-like  Sarcoma  of  the  Vagina  (Rhabdomyosarcoma),  Show- 
ing THE  Vesicular  Polypi  Filling  the  Vagina,  and  the  Infiltration  op 
THE  Vaginal  Walls  (Kelly). 

The  upper  portion  of  the  greatly  distended  bladder  is  seen  above  and  in  front 
of  the  uterus. 


other  hand,  it  is  noteworthy  that  young,  striated  muscle  fibers  bear  a 
close  resemblance  to  sarcoma  cells. 

The  diagnosis  of  rhabdomyoma  is  rendered  difficult  because  of  the 
absence  of  distinguishing  clinical  characteristics.    The  behavior  of  the 


RHABDOMYOMATA  1219 

growth  would  justify  the  assumption  that  the  surgeon  is  dealing  with 
a  benign  or  a  malignant  tumor,  which  may  be  a  fibroma,  a  sarcoma  or, 
when  located  in  the  genito-urinary  tract,  a  mixed  tumor,  the  identity 
of  which  is  distinguishable  only  with  the  aid  of  the  microscope. 

The  treatment  consists  in  extirpatioyi  of  the  tumor,  the  technic  of 
which  depends  upon  its  location  and  character. 

The  literature  on  the  subject  has  been  collected  by  Steiner^  and  by 
Stumpf,^  especially  the  latter. 

BIBLIOGRAPHY 

1.  Marchand.     Virehow's  Arch.  Ixxiii,  1878,  s,  1885. 

2.  RiBBERT.     Geschwiilstlehre,  Bonn,  1904;  Beitr.  z.  Ensteh.  d.  Geschwiilste, 

Bonn,  1906. 

3.  Steiner.     Beltr.  z.  Klin.  Chir.  xxii,  1898. 

4.  Stumpf.     Ziegier's  Beitr.,  1911,  i. 


CHAPTER  XIV 
TUMORS  COMPOSED  01'  NERVE  ELEMENTS 

Neuromata.  Ganglioneuromata. —  This  group  should  not  include  the 
fibromata,  myxomata  and  sarcomata  of  nerves,  which  are  designated 
as  false  neuromata,  but  should  be  restricted  to  tumors  composed  only 
of  nerve  elements.  They  are  very  rare  and  most  often  arise  from  the 
sympathetic  system,  where  they  appear  as  round  or  nodular,  fibroma- 
like tumors,  at  times  of  considerable  size  (occasionally  as  large  as  the 
adult  head).  Tumors  of  this  sort  have  been  found  in  the  brain  by 
Schmincke^  and  in  the  cranial  nerves  and  the  ganglion  of  Gasser  by 
Risel.2 

Histologically,  neuromata  are  composed  of  closely  interlacing  fib- 
rillae,  consisting  mainly  of  non-medullated  and,  to  a  slight  degree,  of 
medullated  nerve  fibers.  The  spaces  between  the  nerve  fibers  are  more 
or  less  occupied  by  ganglion  cells,  which  appear  as  undeveloped  round 
cells  with  slender  axis  cylinder  prolongations.  In  addition  to  this, 
the  growth  contains  connective  tissue  cells  of  the  neurolemma,  inter- 
stitial tissue,  and  a  few  blood  vessels.  When  ganglion  cells  are  pres- 
ent in  addition  to  nerve  fibers,  the  term  ganglioneuroma,  or  neuroma 
gangliocellulare,  is  used. 

In  the  not  large  number  of  reported  cases,  the  lesion  appeared  in 
children  and  in  young  persons  in  the  form  of  encapsulated  tumors 
situated  on  or  near  a  sympathetic  ganglion  (usually  behind  the  peri- 
toneum, to  the  left  of  the  vertebral  column)  ;  or  in  multiple  form  as 
small  tumors  in  the  skin,  where  they  are  believed  to  originate  from 
the  small  sympathetic  ganglionic  cells  in  the  walls  of  the  blood  vessels 
(Kjiauss^).  Hook*  found  a  ganglion  neuroma  within  the  right  kidney. 
Genuine  netiromata  were  regarded  as  benign  until  both  Beneke^  and 
Mil/ler®  reported  reptroperitoneal  lesions  with  metastases  in-  the  lymph 
nodes.  Wrighf^  and  SjTnmers^  have  presented  interesting  studies  of 
similar  cases  and  WahP  presents  a  resume  of  the  literature  up  to  1914. 

The  dearth  of  clinioal  material  makes  futile  a  discussion  of  the 
diagnosis. 

1220 


TUMORS  COMPOSED  OF  NERVE  ELEMENTS        1221 

The  origin  of  ganglion  neuromata  is  obscure.  Their  appearance 
early  in  life  and  their  congenital  occurrence,  together  with  the  incom- 
plete development  of  the  nerve  elements  of  which  they  consist,  suggest 
disturbances  in  development  of  the  sympathetic  system  (Ribbert^°). 

The  treatment  consists  in  extirpation,  when  the  tumor  is  accessible. 

Traumatic  neuroma  is  a  term  applied  to  small  nodular  areas  of 
thickening  which  appear  in  connection  with  injuries  to  nerves;  how- 
ever, they  are  not  genuine  tumors.  They  develop  especially  in  amputa- 
tion stumps  (so-called  amputation  neuromata)  on  the  central  ends  of 
fully  severed  nerves  or  on  the  sides  of  partially  divided  nerves.  The 
lesion  develops  as  the  result  of  mechanical  irritation  of  nerves  located 
beneath  the  skin,  in  scar  tissue,  or  on  the  edge  of  a  bone  (in  the 
lower  jaw  or  at  the  supraorbital  ridge  following  an  injurjO-  Tumors 
of  this  sort  are  composed  of  proliferated  nerve  connective  tissue  and 
regenerated  non-meduUated  and  medullated  nerve  fibers  which  form 
an  irregular,  more  or  less  interlaced  network.  The  process  is  regarded 
as  an  excessive  regenerative  proliferation  of  nerve  elements.  The  size 
of  the  nodules  rarely  exceeds  twice  the  diameter  of  the  affected  nerve. 

Traumadic  neuromata  are  easily  recognized;  they  are  small,  hard 
masses,  exceedingly  tender  upon  pressure,  and  located  in  or  near  a 
scar. 

They  are  easilj^  removed.  In  performing  amputations,  the  high 
division  of  nerv'e  trunks  obviates  their  occurrence. 

BIBLIOGRAPHY 

1.  ScHMiNCKE.     Beitr.  z.  path.  Anat.,  Bd.  47,  1910. 

2.  RiSEL.     Verb.  d.  path.  Gesel.,  1909. 

3.  KxAUSS.     Virchow's  Arch.  Bd.  153,  1898,  with  lit. 

4.  Hook.     Frankfurter  Zeitsehr.  f.  path.,  Bd.  7,  1911. 

5.  Beneke.     Beitr.  z.  path.  Anat.,  Bd.  30,  1901. 

6.  Miller.     Virchow's  Arch.  Bd.  191,  1908. 

7.  "Wright.     Jr.  Exper.  Med.,  1910,  xii. 

8.  Symmers.     Jr.  A.  M.  A.,  1913,  Ix. 

9.  Wahl.     Jr.  Med.  Research,  1914,  xxx. 

10.     Ribbert.     Geschwiilstlehre,     Bon-n,     1904,     and    Beitr.     z.     Ensteh.     d. 
G^schwiilste,  Bonn,  1906. 


CHAPTER  XV 

GLIOMATA 

Gliomata  is  a  term  applied  to  tumors  composed  of  the  neuroglia 
(the  stroma)  of  the  central  nervous  sj^stem.  They  occur  in  the  hrain, 
the  spinal  cord  and  the  eye.  In  the  last  situation,  they  present  certain 
histological  peculiarities. 

In  the  brain,  gliomata  occur  in  both  the  gray  and  the  white  matter ; 
they  vary  from  the  size  of  a  cherry  to  that  of  the  adult  fist,  and  may 
involve  an  entire  hemisphere.  The  borders  of  the  lesion  merge  into 
the  surrounding  tissues,  which  take  on  the  grayish  red  color  and  vary- 
ing consistence  of  the  lesion,  making  the  normal  structures  of  a  patho- 
logical process  consist  in  a  flattening  of  the  surface  convolutions  and, 
on  section,  the  presence  of  hemorrhagic  foci,  areas  of  neerosis,  or  of 
cystic  degeneration.  Gliomata  often  appear  early  in  childhood,  and 
at  times  are  present  in  multiple  form,  at  birth.  In  the  latter  instance 
they  consist  of  a  number  of  small  nodules  located  on  the  inner  surface 
of  the  ventricles.  The  growth  of  gliomata  is  usually  very  slow ;  it  is 
rapid  only  in  tumors  rich  in  cellular  elements.  The  process  is  infiltrat- 
ing (rarely  expansive)  and  destroys  the  brain  tissue  as  it  progresses; 
however,  it  does  not  extend  beyond  the  brain  itself. 

The  clinical  picture  depends  upon  the  seat  of  the  tumor  and  the 
degree  of  intracranial  pressure  it  produces  (for  instance,  brain  tumor), 
to  which  must  be  added  the  sudden  disturbances  indicative  of  cere- 
bral hemorrhage  {apoplectic  attacks). 

Gliomata  of  the  spinal  cord  also  appear  most  often  in  early  life. 
They  are  located  in  the  substance  of  the  cord  and  often  lie  within  the 
central  canal.  They  form  slowly  growing,  slender,  pencil-like  masses, 
or  convert  considerable  sectors  of  the  cord  into  a  grajnsh  mass,  so 
that  only  a  thin  encasing  portion  of  the  normal  tissue  remains.  In 
some  instances,  the  growth  extends  beyond  the  confines  of  the  cord  and 
extends  to  the  pia  (Pels-Leusden^).  At  times,  hollow  spaces  are  found 
in  the  center  of  tumors  of  this  sort,  which  represent  a  certain  form  of 
syringomyelia.  An  extended  study  of  the  lesion  has  been  made  by 
Landau^  and  Flexner.^ 

1222 


GLIOMATA 


1223 


The  clinical  manifestations  are  lliose  of  tumors  of  the  spinal  cord. 

The  dangers  of  gliomata  of  the  hrain  and  spinal  cord  are  determined 
by  their  seat.  Their  extension  by  infiltration  is  in  close  imitation  of 
the  behavior  of  malignant  processes;  however,  they  grow  very  slowly, 
do  not  invade  contiguous  tissues,  and  do  not  give  rise  to  metastases. 


Fig.  593A. —  Glioma  op  Pons, 


Gliomata  of  the  eye  originate  from  the  glial  constituents  of  the 
retina,  or  from  some  earlier  developmental  stage  of  the  cells  of  this 
membrane,  and  grow  out  into  the  vitreous  humor,  pushing  the  retina 
forward ;  or  they  may  extend  backward  along  the  course  of  the  optic 
nerve  into  the  brain.     They  are  seldom  bilateral,  sometimes  are  cour 


1224 


TUMORS 


genital,  and  rapidly  destroy  the  eyeball.  Recurrences,  even  after  com- 
plete extirpation  of  the  contents  of  the  orbital  cavity,  are  not  uncom- 
mon ;  indeed,  the  likelihood  of  metastatic  formation  in  the  brain  makes 
the  outlook  in  these  cases  exceedingly  unfavorable. 

Histologically  (Fig.  593B),  gliomata  of  the  brain  and  spinal  cord  are 
found  to  be  composed  of  glia  cells  and  a  network  of  interlacing 
fihrillae,  the  latter  being  spindle  or  pencil  shaped  processes  of  the  for- 
mer.   The  proportion  of  fibrillae  determines  the  hardness  of  the  tumor 


Pig.  593B.—  Glioma, 

Showing  neuroglia   cells  loosely  enmeshed   in  fibrils    (Symmers,  Bellevue  Hos- 
pital case). 


mass.  At  times  a  tumor  section  reveals  the  presence  of  small  or  large, 
round  or  cleft  shaped,  hollow  spaces  lined  with  cylindrical  cells.  The 
latter  are  believed  to  be  derived  from  ependyma  epithelium,  and  as  the 
glia  cells  arise  from  this  source,  they  probably  represent  the  prestage 
of  tumor  cells.  "When  proliferated  ganglion  cells  and  nerve  cells  are 
present,  the  tumor  is  called  a  neuroglioma  ganglionare.  "When  spindle 
shaped  ganglion  cells  are  present  in  large  numbers  and  the  fibrillae 
are  not  clearly  defined,  the  lesion  may  be  mistaken  for  sarcoma. 

Gliomata  of  the  eye  are  composed  of  numerous  round  or  oval  cells 


GLIOMATA  1225 

without  the  projections  described  above,  and  a  meager  amount  of 
fibrillar  substance.  They  also  contained  radially  arranged  cylindrical 
cells,  not  unlike  a  rosette,  inclosmg  a  minute  lumen.  These  cells 
{neuro-epithelial)  originate  from  the  outer  layer  of  the  retina.  Win- 
tersteiner*  calls  the  growth  a  neuro-epitheUoma. 

That  the  origin  of  glioma  is  traceable  to  developmental  anomalies  is 
shown  by  the  presence  in  the  tumor  of  embryonic  cells,  by  the  fact 
that  it  is  congenital,  and  by  its  bilateral  occurrence  in  the  eyes.  To 
this  may  be  added,  that  gliomata  of  the  brain  and  cord  often  coexist 
with  other  malformations  (Ribbert^). 

The  dia<guosis  may  be  made  when  both  eyes  are  simultaneously 
involved.  When  the  lesion  is  unilateral  the  diagnosis  is  limited  to  the 
presence  of  a  tumor  the  nature  of  which  suggests  sarcoma. 

The  treatment  of  gliomata  of  the  eye  consists  in  extirpation  of  the 
contents  of  the  orbital  cavity.  In  gliomata  of  the  brain  and  cord,  the 
surgeon  is  often  confronted  with  the  infiltrating  form  of  the  lesion, 
which  is  not  susceptible  to  surgical  relief. 

BIBLIOGRAPHY 

1.  Pels-Leusden.     Beitr.  z.  path.  Anat.  xxiii,  1898. 

2.  Landau.     Frankfurter  Zeitschr.  d.  Path.,  1910,  v. 

3.  Flexxer.     Johns  Hopkins  Hosp.  Bull,  1891,  ii. 

4.  "WiNTERSTEix.     Uber  das  Neuroepithelioma.  Leipzig,  1897,  with  lit. 

5.  RiBBERT.     Geschwiilstelehre,  Bonn,  1904  j  Beitr.  z.  Ensteh.  d.  Gesehwiilste, 

Bonn,  1906. 


CHAPTER  XVI 

TUMORS  DEVELOPING  FROM  EPITHELIUM 

riBRO-EPITHELIAL  TUMORS. 

Fihro-epithelial  growths  are  the  outcome  of  the  proliferation  of 
epithelial  cells  and  connective  tissue,  although  they  may  vary  in  their 
degree  of  development.  In  carcinoma,  connective  tissue  fills  a  subor- 
dinate part  and  is  concerned  only  in  furnishing  support  for  the  blood 
vessels  (Ribbert^).  The  relationship  that  the  epithelial  and  connective 
tissues  hear  to  each  other  is  similar  to  that  of  normal  tissue.  In  papil- 
lomata  these  are  the  same  as  exist  in  the  skin  and  mucous  membranes ; 
in  adenomata,  their  arrangement  resembles  the  structure  of  a  gland ; 
and  the  structure  of  epithelial  cysts  resembles,  in  a  number  of  waj'S, 
that  of  the  skin  and  mucous  membranes. 

Papillomata. —  Papillomata  are  circumscribed,  usually  small  (rarely 
larger  than  a  hen's  egg),  expansive  surface  tumors,  the  connective 
tissue  of  which  contains  elongated,  many  branched  papillae  and  nume- 
rous blood  vessels.  These  papillae  are  completely  covered  with 
epithelium.  "When  the  connective  tissue  holds  the  papillae  in  close 
apposition  the  process  appears  in  the  form  of  a  round  nodule  or  wart. 
When  the  papillae  and  their  branches  are  covered  with  a  symmetrical 
layer  of  epithelium  and  are  not  confined  by  connective  tissue,  they 
stand  out,  more  or  less  independently,  and  appear  as  delicate,  fissured, 
villous  tumors  resembling  ra.spberries  and  grape  clusters,  growing 
from  the  skin  or  mucous  membranes,  and  attached  to  them  by  rather 
slender  pedicles.  An  additional  form  is  the  outcome  of  cornification 
of  the  epithelium  (in  papilloma  of  the  skin).  Papilloma,  which  is  a 
l)enign  growth,  does  not  extend  helow  the  suh epithelial  tissue. 

On  the  skin  and  mucous  menihranes  papillomata  appear  singly  or  in 
multiple  form  as  pedunculated  or  widely  attached  tumors.  They  are 
often  grouped  together  and  grow  very  slowl}^  When  injured  and 
caused  to  bleed,  or  when  traumatized  in  unsuccessful  efforts  at  removal 
by  strangulation,  the  use  of  acids,  etc.,  they  become  inflamed  and  are 

1226 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1227 


likely  to  grow  at  an  accelerated  rate.     As  a  rule,  when  a  certain  size  is 
reached  they  cease  to  grow. 

The  coruification  of  the  dome  of  papillomata  of  the  skin  makes  them 
harder  than  those  of  mucous  membranes.  Cutaneous  papillomata 
occur  most  often  in  elderly  persons  and  are  usually  found  in  the  axilla, 
the  groin,  the  folds  beneath  the  mammae,  on  the  back,  the  perineum, 
at  the  arms,  and  also,  though  less  often,  upon  portions  of  the  body 
irritated  by  sweat,  friction,  or  lack  of  cleanliness.  In  the  temporal 
region  they  occur  in  connection  with  seborrhea. 


Fig.  594. —  Papillomata  op  the  Axal  Eegiox. 
(Symmers,  Bellevue  Hospital  case). 

Tte  pointed  condylomata  found  on  the  external  genitals,  due  to  the 
irritation  of  gonorrheal  secretion,  possess  the  same  structure  as  papil- 
lomata. They  are  not  tumors,  however,  but  hyperplastic  growths 
developing  upon  a  chronically  inflamed  area.  This  is  shown  by  the 
fact  that  they  disappear  when  the  cause  is  removed. 

Papillomata  of  squammis  mucous  memhranes  of  the  huccal  cavity 
appear  on  the  lips,  the  cheeks,  the  soft  palate,  and  the  tongue,  and  often 
develop  at  the  site  of  a  leukoplakic  spot.  They  also  appear  in  the 
pharj-nx,  the  larynx,  the  esophagus,  and  the  vagina.  With  the  excep- 
tion of  laryngeal  papillomata,  these  growths  are  usually  found  in  old 


1228 


TUMORS 


persons.     Occasionally,  they  are  congenital.     Those  of  the  larynx  are 
likely  to  recur  after  extirpation. 

The  mucosa  of  the  bladder  and,  in  rare  instances,  that  of  the  ureter 
and  kidney  pelvis  are,  at  times,  the  seat  of  single  or  multiple  so-called 
villous  polypi.  These  consist  of  soft,  pedunculated  growths,  often  the 
size  of  the  adult  fist ;  they  bleed  easily  and  in  the  cj-stoscopic  picture 
appear  as  delicate,  seaweed-like,  floating  villi.  Their  surface  is  covered 
with  several  layers  of  transitional  forms  of  epithelium..    Carcinoma 


Fig.  595. —  ViLLOtrs  Polyp  op  the  Urinary  Bladder. 
Pedunculated  tumor  the  size  of  a  fist,  in  a  man  sixty-five  years  of  age. 

often  appears  in  similar  form  and  may  originate  from  a  papillomatous 
growth. 

Papillary  new  growths  do  not  often  develop  upon  mucous  membranes 
covered  with  cylindrical  epithelium  and  are  almost  entirely  limited  to 
the  rectum,  though  they  also  at  times  appear  in  the  nose,  the  uterus, 
the  stomach,  and  the  biliary  passages.  In  the  rectum  they  vary  in 
size  from  a  pea  to  a  hen's  ^^^,  are  soft  in  consistence,  and  are  attached 
to  the  mucosa  by  slender  pedicles  or  by  a  broad  base  {villous  polypi  — 
tumor  villosus).     When  injured  by  hard  feces  they  bleed  profusely. 

Excessive  cornificatimi  of  the  epithelium  causes  the  formation  of 
horny  warts  and  cutaneous  horns. 

Horny  warts  are  small  (size  of  a  pea),  usually  flat,  fissured  eleva- 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1229 

tions  of  the  skin  with  a  layer  of  hard  epidermis  which  holds  the  clefts 
of  the  papillae  together.  They  are  found  at  all  times  of  life,  chiefly  on 
the  fingers,  and  often  disappear  spontaneously,  especially  when  injury 
causes  a  slight  inflammation. 

Cutaneous  hams  {co-rnua  cutanea)  occur  usually  late  in  life  and 
are  most  often  situated  upon  the  scalp  and  the  face  (the  nose,  the  eye- 
lids, the  ears,  the  cheeks,  and  the  lips)  (Fig.  596).  They  also,  though 
infrequently,  appear  upon  the  trunk,  on  the  limbs  and  on  the  prepuce 
and  scrotum.  Multiple  horns  are  very  rare.  They  hegin  as  small 
warty  nodules  in  the  skin  and  slowly  assume  fantastic  shapes.  As  the 
process  progresses  the  growth  develops  into  either  short,  broad,  conical 
teats  or  narrow,  long  (10-30  c.cm.),  clawlike,  curved  or  twisted  horns, 
dark  brown  or  black  in  color,  and  with  longitudinal  striations.     The 

Sskin  of  the  base  of  the  growth  is  usually 
slightly  reddened.     When  sectioned  in 
its  long  diameter,  the  horn  is  found  to 
consist  of  a  hard  exterior  filled  with  a 
friable  mass;  and  the  microscope  shows 
it   to   consist   of   long  slender   papillae 
which    extend    far    into    the    epithelial 
proliferation. 
At   times,    the    growth    is   devoid   of, 
Fig.  596.— Cutaneous  Horn       papillary    substance.       Occasionally,    a 
ON  THE  Nose.  cutaneous  horn  develops  from  a  papil- 

loma or  from  an  atheroma  (Burckhardt-).  Unlike  horny  warts,  the 
cutaneous  horns  grow  again  after  forcible  removal,  unless  the  skin 
is  excised  with  them.  Papillomatous  growths  are  at  times  located 
upon  the  lining  membrane  of  the  cerebral  ventricles.  They  are  con- 
nected with  either  the  ependymal  epithelium  or  the  choroid  plexus. 
Papillomata  develop  most  often  in  situations  subjected  to  prolonged 
irritation.  Ribbert^  has  caused  their  growth  by  repeated  injury 
(experimental)  of  a  restricted  section  of  the  lip  of  the  rabbit.  Their 
congenital  presence  suggests  emhryonic  disturbances  as  a  causative 
factor.  The  development  of  a  squamous  epithelial  tumor  on  a  mucous 
membrane,  normally  covered  with  cylindrical  epithelium,  supports 
this  view. 

The  clinical  significance  of  papillomata  relates  to  the  hemorrhage 
which  often  occurs  as  the  result  of  injurj',  especially  in  the  soft  forms 
of  the  disease.     The  other  disturbances  depend  upon  the  location  of 


1230  TUMORS 

the  process.  In  the  la/rynx  the  obstruction  to  respiration  they  cause 
is  often  menacing.  At  the  eyelids  and  lips  they  cause  deformation, 
such  as  ectropium,  etc.  They  are  frequently  the  precursors  of 
carcinoma. 

The  treatment  consists  in  removal  of  the  growth  and  excision  of  its 
base.  Small  papillomata  of  the  skin  may  be  destroyed  with  fuming 
nitric  acid.  Those  of  the  mucosa  may  be  cut  off  and  the  base  destroyed 
with  the  thermocautery.  When  broadly  attached  growths  are 
removed,  the  skin  should  be  excised  wnth  them  by  means  of  elliptical 
incisions.  For  the  purpose  of  removing  larg«  papillomata  of  the 
larynx,  'bladder,  etc.,  more  or  less  elaborate  operative  measures  of 
approach  are  necessary  (laryngofissure,  preliminary  cystotomj^,  etc.). 

Incomplete  removal  of  the  process  is  followed  by  rapid  recurrence. 

Adenomata. —  Adenomata  are  fibro-epithelial  tumors  of  glandular 
organs,  the  epithelial  cells  of  which  retain  their  glandular  arrange- 
ment. Their  character,  i.  e.,  the  form  of  cells  and  the  secretion- they 
contain,  depends  upon  the  structure  of  the  tissue  in  which  they 
originate. 

Adenomata  of  the  skin  and  mucous  membrane  differ  from  hyper- 
plastic proliferation  in  that  they  do  not  reproduce  the  form  and  struc- 
ture of  the  normal  gland,  are  encapsulated,  and  have  no  functional 
connection  with  the  tissues  in  which  they  develop  (Ribbert^). 

Most  adenomata  are  henign  tumors.  However,  a  small  number 
invade  the  surrounding  tissues  and  form  metastases. 

Adenomata  of  the  Skin. —  Adenomata  of  the  skin  are  not  always 
readily  differentiated  from  simple  hyperplasia  of  the  sebaceous  glands. 
They  are  of  importance  because  of  the  frequency  with  which  carcinoma 
develops  within  their  structure. 

Adenomata  of  the  sebaceous  glands  (adenomata  sebacea)  occur 
mostly  on  the  face  in  either  single  or  multiple  form.  Thej^  are  cir- 
cumscribed (the  size  of  a  pea  or  that  of  a  walnut),  soft  warty 
nodules,  usually  dark  red  or  brown  in  color,  and  at  times  resemble 
translucent  mother  of  pearl.  They  consist  of  small  epithelial  lobules 
resembling  the  structure  of  a  sebaceous  gland  and  are  embedded  in  a 
delicate  connective  tissue  stroma. 

Sebaceous  adenomata  usually  appear  in  old  persons,  grow  very 
slowly,  and  often  develop  in  an  area  of  seborrheic  eczema.  Spontane- 
ous disintegration  of  the  epithelial  cells,  and  hyalin  degeneration  of  the 
connective  tissue  and  blood  vessels,  or  a  slight  injury  often  cause  them 
to  ulcerate.     A  certain  number  of  tumors  of  this  sort  calcify  (so-called 


TUMOKS  DEVELOPING  FROM  EPITHELIUM        1231 

calcified  epithelioma)  or  are  transformed  into  earcinomata  (Landau^). 

Clinically,  sebaceous  adenomata  are  not  readily  differentiated  from 
Rndotheliomata,  degenerated  flat  earcinomata  of  the  skin,  and  sudori- 
parous adenomata. 

Tliey  are  readily  destroyed  by  cautery  or  the  X-ray;  however, 
excision  is  the  more  desirable  method  of  treatment. 

Adenomata  of  sweat  glands  {adenoma  sudoripara)  are  rare,  usually 
single,  occasionally  multiple,  tumors  which  appear  as  nodules  in  the 
skin  and  suhcutaneoxis  tissues  of  the  face,  scalp,  hreast,  hack,  navel, 
groin,  labia  and  extremities. 

Sudoriparous  adenomata  may  appear  during  childhood,  but  are  more 
common  in  old  persons,  and  groiv  slowly.  The  cutaneous  form  appear 
as  small  nodules  or  forms  a  small,  pale,  sausage  form  elevation,  which 
is  not  movable  with  the  skin.  The  subcutaneous  form  is  covered  with 
normal  skin  for  a  long  time.  The  growth  at  times  reaches  the  size  of 
a  saucer  or  larger,  and  may  be  attached  to  the  skin  by  a  pedicle.  In 
this  event,  it  is  very  likely  to  ulcerate  and  is  often  covered  with 
crusts.  The  consistence  of  the  tumor  depends  upon  whether  cysts 
develop.  The  ulcerated  surfaces  are  very  obstinate  and  are  likel}^  to 
give  origin  to  flat  earcinomata. 

Sudoriparous  adenomata  consist  of  dilated  and  cystic  gland  tubules 
lined  with  cylindrical  epithelium.  The  tumors  are  often  arranged  in 
the  form  of  papillary  growths ;  they  are  rich  in  connective  tissue  and 
are  sharply  defined  against  the  surrounding  tissues. 

Clinically,  they  are  not  easily  diagnosticated  from  sehaceous  adeno- 
mata, suhcutaneous  lipomata  or  small  lymphangiomata.  Microscopi- 
cally, they  resemble  endotheliomata  and  hasal  cell  earcinomata. 

Adenomata  of  the  Mucous  Membraxes. —  As  chronic  inflamnmtory 
processes  in  mucous  membranes  are  always  attended  wdth  proliferation 
of  glandular  structures  (especially  in  the  nose  and  its  accessory  sinuses, 
the  gut,  and  the  urinary  passages),  which  often  takes  on  a  polypous 
form,  and  as  adenomata  of  mucous  membranes  also  appear  in  the  form, 
of  polypi,  their  differentiation  is  attended  with  considerable  difficulty. 
Polypous  h3T3erplasia  may  be  regarded  as  adenomatous  when  the 
process  contains  gland  structure  which  deviates  from  that  of  the 
normal. 

Adenomata  of  mucous  membranes  are  benign  tumors  which  never 
extend  into  the  deeper  tissues.  The  submucosa  and  the  muscularis 
take  part  in  the  process  to  the  extent  of  a  moderate  degree  of  connec- 
tive tissue  hyperplasia.     Their  form  and  size  vary  widely.     As  a  rule, 


1232 


TUMORS 


they  are  smooth  or  slightly  nodular,  and  are  covered  with  almost 
normal  mucous  membrane. 

In  the  7iose,  adenomata  appear  as  soft  polypi  or  pedunculated  grape 
cluster-like  masses,  the  connective  tissue  stroma  of  which  contains 
dilated,  cystic  mucous  glands,  filled  with  watery  fluid. 

Adenomata  of  the  g astro-intestinal  tract  may  be  single,  but  are 
usually  multiple.  They  appear 
in  the  form  of  polypi  with  thin 
pedicles,  or  as  smooth  or  nodu- 
lar tumors  covered  with  thick- 
ened mucosa,  and  vary  in  size 
from  a  pea  to  an  adult  fist. 

In  the  stomach  they  often 
develop  at  the  pylorus,  where 
they  originate  from  the  pyloric 
glands.  In  this  situation  they 
may  cause  obstruction  and  are 
likely  to  be  mistaken  for  carci- 
noma (Lexer*). 

In  the  gut,  adenomata  de- 
velop from  Brunner's  glands 
(duodenum)  and  from  the  fol- 
licles of  Lieberkiihn.  They  are 
likely  to  be  numerous  in  the 
lower  sectors  of  the  colon.  At 
times,  the  intestinal  mucosa  is 
so  plentifully  studded  with 
adenomata  that  it  has  a  shaggy 
appearance,  at  others  the 
tumors  are  more  widely  sepa- 
rated (Fig.  597).  In  another 
class  of  cases,  the  tumor  masses 
reach  the  size  of  a  walnut. 
Pedunculated  tumors  are  espe- 
cially liable  to  be  injured  by  the  passage  of  feces,  which  gives  rise  to 
more  or  less  severe  bleeding  and,  in  some  instances,  the  activities  of 
the  lower  bowel  cause  the  growth  to  protrude  from  the  anus,  while 
it  is  attached  to  the  mucosa  by  a  much  stretched  pedicle.  When 
pedunculated  tumors  are  located  higher  in  the  gut,  they  occasionally 
cause  invagination. 


Fig. 


597. —  Multiple  Polypoid   Adeno- 
mata OF  THE  Colon. 


(Symmers,  Bellevue  Hospital  case). 


TUMORS   DEVELOPING  FROM  EPITHELIUM        1233 


Bleeding  after  a  stool  and  secondary  anemia  should  arouse  suspicion. 
In  some  instances,  a  polypus  of  this  sort  may  be  felt  through  the  anus. 
The  treatment  of  pedunculated  tumors  consists  in  excision  of  the 
tumor  at  its  attachment. 

Multiple  adenomata  of  the  gut  provoke  a  menacing  clinical  picture. 
The  symptoms  usually  begin  with  evidences  of  a  severe  intestinal 
catarrh,  which  is  soon,  followed  by  bleeding  and  the  passage  of  par- 
ticles of  tissue.  In  not  a  few  cases,  the  process  becomes  malignant 
{adenocarcinoma).  Doring^  collected  fifty  cases,  of  which  thirty- 
seven  died ;   of  these,  thirty  died  of  carcinoma. 

The  diagnosis  is  estab- 
lished by  the  findings 
upon  examination  of  the 
rectum. 

Adenomatous  polypi 
also  develop  from  the 
uterine  mucosa  (from 
remnants  of  the  vitelline 
duct)  at  the  navel  of 
children. 

Adenomata  of  mucous 
membranes  originate  as 
the  result  of  develop- 
men tal  a n  o m  alies  in 
which  small  sections  of 
mucous    membrane    are 


Fig.  598. —  Cystic  Adenoma  of  the  Parotid  Gland. 


excluded  from  the  phj'siological  environment   (Ribbert^). 

The  treatment  consists  in  extirpation  of  all  accessible  tumors.  Those 
of  the  gastrointestinal  canal,  in  accord  with  their  location,  may  be 
removed  by  the  rectum  or  after  celiotomy.  The  extent  of  the  lesion 
decides  the  usefulness  of  the  method.  In  any  event,  recurrences  are 
very  likely  to  develop. 

Adenomata  of  the  Salivary  Glands. —  Adenomata  of  the  parotid 
(Fig.  598),  suhmaxillary,  and  suMingual  glands  are  very  rare.  They 
appear  as  slowly  growing,  encapsulated,  soft  masses  (Kiittner,® 
Nasse^). 

Adenomata  of  Glandular  Organs. —  Adenomata  of  glandular 
organs  are  henign  tumors,  usualh'  encapsulated,  but  may  invade  the 
lumen  of  blood  vessels  and  form  metastases,  in  which  instance  they  are 


1234 


TUMORS 


regarded  as  malignant  {malignant  adenomata).  In  tliese  tumors  tlie 
arrangement  of  the  epithelium  resembles  that  of  normal  glandular 
organs  but  histologically  presents  certain  differences.  Connective  tis- 
sue and  epithelial  cells  are  present  in  varying  proportions.  The  pre- 
dominance  of  connective  tissue  imparts  to  the  tumor  the  hard  con- 
sistence of  a  fibroma  (fihro-adenoma)  ;  when  the  connective  tissue  is 
rich  in  cellular  elements  the  term  adenosarco'ma  is  used,  and,  when 
mucoid,  the  growth  is  called  adenomyxofihr&ma  (cystosarcoma  phyl- 
lodes,  myxofibroma  intercanaliculare) .  "When  tumors  consist  largely 
of  epithelial  cells,  these  may  be  cylindrical,  cubical,  flat  or  irregular 
and  aranged  either  in  tubules,  when  they  develop  into  tubular  adeno- 
mata, or  in  alveoli  which  resemble  the  lobuli  of  glands,  in  whicli 
instance  they  take  on 
the  form  of  alveohtr^l'.^- ?-^'jj^ 
adenomata.  Dilata- 
tion of  either  tlie 
tubules  or  the  al ver )1  i 
results  in  the  de- 
velopment of  cysts 
(cyst  ad  e  nam  at  a) . 
The  proliferatiou  of 
branching  papillae 
into  tubules  or  alve- 
oli is  responsible  for 
the  formation  of  a<h 
nomata  or 
nomata  papilli 
{papilloma 
intracan  a  I  icularc) .       Fig.  599. 


cystmh-  Yir^X^Ki'.-^^iJ^^'i^^ 


Cystadenoma  of  the  Mammary  Gland. 
Adenomata  of  the  ^'  Alveolar  Arrano-emcnt  of  Epithelium,  at  other  points 

a  Tubular  Arrangement. 
m  ammary    gland 

form  slowly  growing,  round  nodules,  var.ying  in  size  and  consistence. 
They  may  be  multiple  in  one  or  in  both  breasts,  are  benign  in  character 
and  encapsulated,  though  they  recur  unless  completely  removed.  Their 
circumscribed  form  readily  differentiates  them  from  diffuse  hyperplasia 
of  the  breast.  They  often  occur  in  young  women,  very  rarely  in  men, 
and  at  times  (especially  in  the  cystic  form)  attain  considerable  size.  As 
the  growth  increases,  the  skin,  which  is  at  first  unchanged  and  movable, 
becomes  atrophied  and  may  undergo  necrosis,  so  that  the  tumor  pro- 
trudes'bej^ond  the  surface.  On  section,  simple  tubular  or  alveolar  adeno- 
mdta,  because  of  the  predominance  of  connective  tissue,  presient  a 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1235 

smooth,  grayish  red,  hard  surface  (fihro-adenoma) .  When  the  tubules 
are  dilated  into  clefts  or  cijsts,  the  growth  is  a  cxjstadenoma.  If  these 
clefts  are  invaded  by  connective  tissue  projections,  which  elevate  the 
epithelial  cells  into  papillae,  a  lohulated  grape  cluster-like  proliferation 
into  the  cysts  takes  place  and  the  tumor  is  designated,  in  accord  with 
the  character  of  the  tissue  in  which  it  develops,  as  a  cystadenoma,  a 
cystis  papillaris,  a  cystis  papillifcra,  a  cyst  fibroma,  a  myxoma  intra- 
canaliculare,  or  as  a  sarcoma  ahorescens  or  sarcoma  phyllodes.  The 
breasts  of  elderly  wamen  are  often  the  seat  of  multiple  cysts,  which 
Schimmelbusch^  calls  cystadenomata.     However,  the  lesion  is  regarded 


Fig.  600. —  Adexomatous  Xodules  nsr  the  Thyroid  Gland. 
Some  of  these  contain  colloid  (from  MacCallum's  "  Text  Book  of  Pathology"). 

by  Koenig^  and  others  as  the  result  of  chronic  inflammation  {mastitis 
chronica  cystica).  Section  reveals  the  presence  of  small  and  large 
brown  cysts. 

Adenomata  of  the  thyroid  gland  differ  from  hyperplastic  enlarge- 
ment (which  obtains  in  most  cases  of  goiter)  in  their  circumscribed 
nodular  form,  which  gradually  increases  to  the  size  of  an  apple.  They 
are  at  times  congenital  and  often  multiple.  Microscopically  (Fig. 
600)  they  are  seen  to  be  composed  of  the  embryonic  type  of  glandidar 
tissue,  which  is  readily  distinguished  from  the  normal.  Occasionally, 
adenomata  of  this  sort  become  malignant,  invade  the  walls  of  a  vein, 
and  portions  of  the  growth  enter  the  blood  stream  and  are  deposited 
in  the  lungs  and  bones,  where  they  seem  to  find  conditions  exceedingly 


1236  TUMORS 

favorable  to  development.     Growths  of  this  sort  are  not  infrequently 
responsible  for  spontaneous  fractures  (Gierke/^  GobeP^). 

Adenomata  of  the  suprarenal  glands  {strumae  suprarenales,  hyper- 
nepJirama)  appear  as  circumscribed  nodules,  the  light  yellow  color  of 
which  makes  them  easily  distinguishable.  They  resemble  the  structure 
of  the  kidney  cortex  and  develop  in  the  adrenal  gland  and  the  kidney, 
in  the  broad  ligament,  in  the  epidermis,  and  in  the  under  surface  of 
the  liver,  where  they  originate  from  displaced  adrenal  rests 
(Albrecht,^^  Beer,!^  v.  Bergmann,^*  Hildebrand,^'  Holst,^^  Sudeck^'). 
At  times,  adenomata  of  the  kidney  (especially  in  children)  develop 
into  a  large-sized  mass  which  causes  the  kidne}^  tissue  entirely  to  dis- 
appear. When  they  break  through  the  kidney  capsule  they  are  likely 
to  gain  access  to  the  renal  vein,  which  is  soon  followed  by  the  develop- 
ment of  metastases.  Grawitz^*  claims  that  adenomata  of  the  kidney 
originate  in  the  adrenal  gland ;  a  view  that  Stork^®  contests. 

Adenomata  of  the  kidney  are  encapsulated,  grayish  white  tumors 
the  size  of  a  cherrj*.  The}"  appear  singly  or  in  numbers  and  are  com- 
posed of  either  tubules  or  hollow  spaces  with  papillary  proliferation. 
They  are  rareh^  malignant. 

Adenomata  of  the  liver  are  composed  of  solid  or  hollow  cell  columns, 
and  at  times  appear  as  round,  soft,  light  brown  nodules,  or  as  large 
pedmiculated  tumors  at  the  edge  of  the  liver.  They  have  a  tendency 
to  extend  by  infiltration  and  assume  a  malignant  character  as  the  result 
of  invasion  of  the  portal  system.  Ribbert^  explains  the  occurrence  of 
many  adenomata  in  this  way;  however,  the  occurrence  of  metastases 
in  the  lungs,  lymph  glands  and  bones  is  comparatively  rare. 

The  development  of  adenomata  in  organs  is  explained  on  the  theory 
of  displaced  germinal  tissue,  which  is  isolated  from  the  parenchyma 
and  assumes  independent  development. 

Adenomata  of  organs  should  be  extirpated  when  possible.  This  may 
demand  the  removal  of  the  organ. 

To  the  adenomata  may  also  be  added  cystic  growths  of  the  various 
organs,  which  are  due  to  disturbances  in  the  development  of  their 
glandular  structures. 

Of  these,  cystadenomata  of  the  ovary  are  the  most  frequent.  They 
form  either  a  single  large  cyst,  or  extensive  tumors  consisting  of  a 
number  of  cysts,  and  are  likely  to  be  bilateral.  Their  walls  are  lined 
with  cylindrical  epithelium,  and  are  more  or  less  covered  with  papillae. 
At  times  the  epithelium  takes  on  a  glandular  arrangement.     When  a 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1237 

cyst  ruptures  into  the  abdominal  cavity,  the  peritoneum  is  likely  to  be 
invaded  by  the  process. 

The  kidney  and  the  liver  may  be  the  seat  of  single  or  multilocular 
cystadenomata,  which  at  times  occupy  the  entire  organ. 

Epithelial  Cysts. —  Tlie  epithelial  cysts  comprise  tumors  which,  in 
greater  part,  are  primarily  cystic  and  consist  of  epithelium  and  con- 
nective tissue.  They  may  be  classed  with  flbro-epithelial  tumors, 
although  many  of  them  closely  resemble  mixed  tumors. 

Dermoids,  or  Dermoid  Cysts. —  Dermoids  are  globular  or  semi- 
glohular,  usually  single  tumors  which  at  times  reach  considerable  size, 
and  as  a  rule  appear  in  very  early  life. 

The  wall  of  a  dermoid  cyst  is  thick  and  resisting,  smooth  without, 
and  white  within,  rough,  and  more  or  less  covered  with  -fine  short,  or 
long  coarse  hairs.  The  inner  layer  of  the  cyst  wall  resenibles  skin, 
and  contains  epidermis,  papillae,  hair,  hair  follicles  and  sweat  glands. 
The  outer  layer  consists  of  coarse  connective  tissue,  the  inner  projec- 
tions of  which  form  the  papillae.  Its  outer  surface  is  loosely  attached 
to  its  surroundings,  so  that  the  cj'st  is  readily  separated  from  its  envir- 
onment, except  when  located  upon  the  skull,  where  it  is  firmly  adherent 
to  the  periosteum.  In  many  dermoids  the  epithelial  lining  is  incom- 
plete. A  certain,  more  or  less  restricted  area  of  the  cyst  wall  is  char- 
acterized by  its  brown  color  and  soft  consistence  and  is  composed  of 
giant  cell  connective  tissue.  The  giant  cells  frequently  contain  hair 
and  fat  crystals  and  are  regarded  as  foreign  body  giant  cells.  The 
contents  of  cysts  of  this  sort  is  composed  of  a  pasty,  yellowish  ivhite 
mass  consisting  of  exfoliated  cells  and  the  secretion  of  the  skin  glands, 
particles  of  fat,  fatty  crystals,  and  cholesterin  plates.  At  times  the 
contents  is  oily  or  watery.  When  bleeding  has  occurred  it  is  reddish 
brown  in  color. 

The  distinguishing  characteristic  of  dermoid  cj'sts  is  that  they  are 
located  in  certain  zones  where  embryonic  development  is  liable 
to  be  atypical.  They  occur  only  in  structures  where  embryonic 
clefts,  furrows  or  folds  of  the  superficial  parts  of  the  body 

coalesce,    OR   WHERE   THE    ECTODERM    IS    INVAGINATED.       The    CUtoneOllS 

germinal  tissue,  invaginated  at  this  time,  gradually  assumes  indepen- 
dent development  and  this  takes  on  the  form  of  a  dermoid  cyst.  For 
this  reason  the  growth  is  not  usually  deeply  located,  and  makes  its 
appearance  early  in  life. 

Of  the  dermoids,  those  of  the  head  and  neck  are  the  most  frequent. 
In  the  region  of  the  eye  (Fig.  601),  their  origin  is  connected  with  the 


1238  TUMORS 

displacement  of  germinal  tissue  of  the  ectoderm,  the  invagination  of 
which  occurs  in  the  formation  of  the  lens  or  during  coalescence  of  the 
nasofrontal  and  superior  maxillary  processes.  They  occur  at  the 
upper  edge  of  the  orbital  cavity,  that  is,  at  the  glabella,  the  root  of  the 
nose,  in  the  outer  or  inner  sectors  of  the  orbit,  or  within  the  orbital 
cavity.  In  the  last  situation  they  often  displace  the  eyeball.  They 
vary  in  size  from  that  of  a  pea  to  that  of  a  walnut.  Dermoids  in  this 
location  are  covered  by  normal,  readily  movable  skin  and  lie  either 
beneath  the  skin  or  under  the  galea  aponeurotica,  the  frontal  portion 


Fig.  601.—  Dermoid  Cyst  at  the  Outer  End  of  the  Supraorbital  Eidge. 

of  the  occipitofrontalis  or  the  orbicularis  oculi  muscles.  When 
deeply  situated  they  produce  pressure  atrophy  of  the  bones  of  the 
skull,  and  at  times  extend  through  the  bone  and  lie  in  contact  with 
the  dura  or  the  inner  aspect  of  the  orbital  cavity.  Occasionally,  an 
external  cyst  communicates  with  an  internal  one,  through  an  opening 
in  the  wall  of  the  orbit.  These  diaphragm  dermoids  are,  however, 
not  the  result  of  the  union  of  two  cysts;  a  single,  preexisting  cyst  is 
gradually  divided  as  the  bone  develops  and  the  two  loculi,  one  internal 
and  the  other  external,  communicate  with  each  other  through  the 
remaining  isthmus  (Kronlein^"). 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1239 

.  The  other  dermoids  of  the  head  are  also  situated  where  invagination 
of  the  ectoderm  occurs.  More  often,  however,  at  the  fontanelles,  the 
ear,  in  front  of  the  tragus,  the  mastoid  (developing  from  the  aural 
anlage  and  the  first  branchial  cleft)  ;  also,  though  less  often,  on  the 
face,  on  the  dorsum,  and  on  the  point  of  the  vose  (median  nasal  cleft), 
in  the  cheek  next  to  the  nasal  alae  (naso-orbital  cleft),  in  the  center  of 
the  cheek  (transverse  cleft  of  the  cheek  between  the  upper  and  lower 
maxillary  processes). 

In  the  face,  it  is  noticeable  that  not  all  the  embryonic  clefts  give 
rise  to  dermoids,  and  that  they  never  occur  in  situations  where  defects 
such  as  harelip  and  cleft  palate  are  found.  This  suggests  that  the 
ectodermal  anlage  is  most  often  invaginated  where  coalescence  occurs 
early  in  fetal  life.  At  the  time  these  clefts  are  obliterated  the  proam- 
nion is  still  in  close  contact  with  the  head  segment,  and  there  is  more 
likelihood  of  the  inclusion  of  ectoderm  than  after  the  formation  of  the 
true  amnion.  Consequently,  in  situations  in  which  the  clefts  coalesce 
late,  there  is  not  much  chance  of  the  development  of  a  dermoid  (v. 
Bramann,^^  Wilms^^). 

In  the  neck,  dermoid  cysts  occur  most  often  below  the  submaxillary 
gland,  where  they  arise  beneath  the  platysma  myoides  from  the  inner 
aspect  of  the  sternomastoid  muscle  and  extend  to  the  digastric  muscle 
in  front,  and  the  trapezius  behind.  They  are  derived  from  the  second 
branchial  cleft.  Occasionally,  they  lie  beneath  the  skin,  in  the  median 
line,  above  or  below  the  lar;^Tix,  and  in  the  jiigulum.  In  the  floor  of 
the  mouth  they  lie  between  the  genioglossi  muscles,  extend  to  the 
tongue,  and  lift  the  mucosa  of  the  floor  of  the  mouth  into  a  dome ;  or 
they  are  located  outside  the  mylohyoid  muscle  and  are  covered  only 
by  the  skin  of  the  submental  region. 

Dermoids  also  develop  in  the  thorax,  where  they  are  situated  either 
in  the  anterior  or  posterior  mediastinum.  In  this  situation,  and  when 
located  in  the  abdominal  wall  at  the  navel,  and  in  the  abdominal  cavity 
in  the  mesejitery  and  omentum,  they  are  included  during  coalescence 
of  the  abdominal  plates.  In  the  connective  tissue  of  the  pelvis  (exclud- 
ing those  associated  with  the  ovary)  they  occur  in  connection  with 
invagination  of  the  perineum.  Cysts  of  the  retroperitoneal  connective 
tissue  in  the  region  of  the  kidney,  arise  from  ectodermal  rests  of  the 
wolffian  ducts.  Those  of  the  scrotum,,  penis,  and  raphe  (which  are 
very  rare)  are  included,  as  these  parts  coalesce  from  either  side.  The 
dermoids  of  the  sacrococcygeal  region  are  very  common  and  are  fre- 
quently the  seat  oi  fistulae,  which  form  sequentiall}^  to  trauma  and 


1240  TUMORS 

consequent  slougliing.  In  a  certain  number  of  cases  the  ultimate  mal- 
formation consists  merely  of  a  depression  of  the  skin.  Those  which 
are  located  in  front  of  the  sacrum  and  coccyx  are  located  beneath  the 
levator  ani  muscle  and  often  form  cloacae  which  open  into  the  peri- 
neum and  simulate  fistulae  due  to  other  causes.  Intracranial  dermoids 
are  very  rare  and  are  usually  situated  at  the  base  of  the  skull,  between 
the  dura  and  bone,  or  beneath  the  pia.  Those  of  the  spinal  column 
occur  in  connection  with  spina  Mfida  or  are  located  in  the  pharynx. 

Dermoids  of  the  testicle  and  ovary  rarelj^  originate  from  the  ecto- 
derm and,  in  most  instances,  coexist  with  other  tumors  —  teratoids. 

On  microscopical  examinatioii,  the  inner  walls  of  many  deraioids 
are  found  not  to  consist  of  cutis,  but  of  several  layers  of  flat  epithelium 
and  of  malpighian  papillae,  without  hair  or  glandular  elements. 
These  are  designated  as  epidermoids  and  are  believed  to  originate  from 
invaginated  emhryonic  skin  tissue  devoid  of  glands  and  hair.  It  is 
suggested  that  dermoids  represent  growths  springing  from  the  ecto- 
derm, invaginated  early  in  its  embryonic  development,  and  thus  are 
evolved  the  various  structures  of  the  skin,  a  view  sustained  by  the 
fact  that  in  postembryonic  transplantation  of  skin,  epithelial  cysts, 
and  not  dermoids,  are  developed  (Lannelongue  et  Achard,^^  Lanne 
longue  et  Menard,-^  Wrede'"). 

Franke^^  includes  atheromata  (p.  1315),  inasmuch  as  they  are  sub- 
cutaneous, with  the  epidernwids,  and  believes  them  to  be  developed 
from  embryonic  tissue  displaced  in  the  anlage  of  the  hair  follicles  and 
glands  of  the  skin. 

Of  the  changes  occurring  in  dermoid  cysts,  the  formation  of  fistulae, 
subsequent  to  trauma  and  infection,  are  the  most  important.  This 
occurs  most  often  in  connection  with  cysts  over  the  coccj^,  for  obvious 
reasons,  since  this  region  is  often  attacked  in  both  sexes,  though  not 
always  with  the  same  intent.  The  character  of  the  fistulous  opening 
is  often  revealed  by  the  discharge  of  hair  due  to  suppuration  of  the 
hair  follicles.  In  a  certain  small  number  of  instances  carcinoma  is 
developed  in  connection  with  a  dermoid  cyst  (H.  Wolff"). 

The  dia:gnosis  of  dermoids  rests  on  the  characteristics  common  to  all 
tumors  of  this  sort.  Their  seat,  and  the  fact  that  they  occur  before 
puberty,  are  important.  The  cysts  are  sharply  circumscribed  and 
smooth,  do  not  merge  into  the  surrounding  tissues,  and  are  covered  by 
normal,  movable  skin.  Their  consistence  varies  with  the  contents. 
At  times,  mdefinite  fluctuation  may  be  elicited;  at  others,  the  tumor 
imparts  a  doughy  sensation  to  the  palpating  finger. 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1241 

Dermoids  of  the  head  are  differentiated  from  atheramata  by  the 
movable  skin  which  covers  the  former.  The  cysts  at  the  fjlahella,  root 
of  the  nose,  and  the  inner  angle  of  the  cue  are  not  readily  separated 
from  encephaloceles  in  these  situations,  especially  when  they  are 
attached  to  the  bone  and  lie  in  a  sharp  bordered  sulcus.  However, 
encephaloceles  are  usually  associated  with  evidences  of  intracranial 
pressure  and  may  be  reduced  in  size  by  manipulation.  Retrobulbar 
orbital  dermoids  cannot  be  distinguished  from  other  slow  growing 
tumors  in  this  situation.  Dermoids  located  in  the  side  of  the  neck 
are  readily  mistaken  for  other  branchiogenic  cysts,  for  tuberculous 
abscesses  of  lymph  nodes,  and  for  lipamata.  Abscess  is  usualh'  attended 
with  palpable  enlargement  of  contiguous  glands,  and  lipoma  is  distin- 
guished by  its  smooth  surface.  Aspiration  is  not  helpful.  Dermoids 
in  the  floor  of  the  mouth  are  situated  in  the  median  line,  ranulae  lie  to 
either  side. 

The  treatment  consists  in  extirpation.  This  is  only  difficult  when 
inflammatory  adhesions  have  occurred;  Incomplete  removal  is  fol- 
lowed by  recurrence.  Simple  incision  does  not  accomplish  the  pur- 
pose. Retroperitoneal  cysts  may  be  incised,  partially  excised,  and  the 
cyst  wall  sutured  to  the  superficial  wound.  This  is  not  always  followed 
by  obliteration  of  the  sac. 

Epithelial  Cysts. —  Not  infrequently  small  round  cysts  which  never 
become  larger  than  a  cherry  appear  in  the  palm  of  the  hand,  and  on 
the  flexor  side  of  the  fingers.  They  usually  develop  in  adult  life 
(mostly  in  men).  The  superimposed  skin  is  slightly  attached  to  the 
cyst,  and,  in  most  instances,  presents  a  tiny  scar  which  reveals  the 
character  and  the  mode  of  development  of  the  cyst.  Its  wall  is  com- 
posed of  loosely  fibered  connective  tissue  which  is  attached  to  the  skin 
and  is  lined  with  a  layer  of  squamous  epithelium.  The  contents  is 
similar  to  that  of  an.  atheroma,  or  consists  of  layers  of  horny  material. 
Cysts  of  this  nature  are  occasionally  found  in  other  portions  of  the 
body.  Cha jes-®  reports  one  of  the  scalp  ;  Lexer*  one  of  the  forehead ; 
and  Kriiger-^  extirpated  one  from  the  trapezius  muscle. 

Traumatic  epithelial  cysts  owe  their  ori{/in  to  the  implantation  of 
particles  of  skin  during  an  injury  (also  during  an  operation, 
Dubreuilh^''),  and,  therefore,  are  called  traumatic  epithelial  cysts 
(Garre^^).  Similar  cysts  develop  also  when  hair  follicles,  sebum  or 
sweat  glands  are  carried  into  the  deeper  tissues  by  a  foreign  body, 
which  becomes  encapsulated  and  the  implanted  elements  proliferate 
and  form  a  cyst  (Pels-Leusden,^-  Hesse^^). 


1242 


TUMORS 


A  cyst  developing  in  connection  with  an  encapsulated  foreign  body 
is  shown  in  Fig.  602.  It  was  located  in  the  center  of  the  palm  of 
the  hand  and  developed  six  months  after  receipt  of  the  gunshot  wound. 
A  small  deformed  lead  projectile  is  encapsulated  in  the  subcutaneous 
tissue.  The  adventitious  capsule  is  not  apposed  to  the  foreign  body 
but  is  separated  from  it  by  a  pasty  mass.  It  lies  in  contact  with  the 
projectile  at  one  side  in  the  form  of  a  round,  cutaneous,  embryonic 
nucleus  which  was  carried  into  the  palm  of  the  hand  with  it.  This 
nucleus  forms  a  portion  of  the  cyst  wall ;  the  rest  of  it  is  composed  of 
squamous  epithelium. 

Similar  cysts  may  be  produced  experimentally.  Ribbert^  imbedded 
portions  of  the  skin  in  the  subcu- 
taneous tissue  and  into  the  abdom- 
inal cavity.  The  implant  healed  in 
situ  and  was  surrounded  by  encap- 
sulating connective  tissue,  which, 
however,  does  not  take  any  part  in 
the  formation  of  the  cyst.  A  cleft 
soon  appears  on  the  epidermal  side 
of  the  transplant ;  this  is  gradually 
filled  with  exfoliated  epithelium 
which  extends  along  its  wall,  and  the 
cyst  forms  in  the  center.  Hesse^^ 
has  produced  epithelial  cysts  by  im- 
planting foreign  bodies  into  the  skin. 
The  implant  was  soon  coA'ered  by 
epithelium  derived  from  the  injured 
area. 

Cholesteatomata.  —  Cholesteato- 
mata,  or  ptarl  tumors,  bea.r  considerable  resemblance  to  dermoids  and 
epidermoids.     The  walls  are  similar  to  those  of  the  last  two  but  the 
contents  of  the  cj'sts  differ. 

The  contents  of  a  cholesteatoma  consists  of  white,  glistening,  concen- 
trically arranged  rmisses  resemhling  mother  of  pearl,  which,  on  section, 
are  likelj^  to  separate  into  thin  lamellae.  They  are  composed  of  corni- 
fied,  compressed  epidermal  scales,  derived  from  the  wall  of  the 
gro-wiihs,  which  are  round,  or  consist  of  several  pearls,  and  contain  fat 
detritus  and  chalesterin.  The  wall  is  composed  of  stratified  epithelium. 
Flat  cells  are  found  in  the  horny  masses;    skin  glands  and  hair  are 


Fig.  602. —  Traumatic  Epithelial 
Cyst  of  the  Index  Finger. 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1243 

rarely  present.  The  outer  wall  is  inclosed  in  a  layer  of  connective 
tissue. 

Cholesteatomata  grow  very  slowly  until  they  reach  the  maximum 
size  of  a  hen's  egg,  or  a  little  larger.  When  pressure  ruptures  the 
capsule,  the  contents  gains  access  to  the  spaces  between  the  surrounding 
tissues.     At  times  the  bone  undergoes  pressure  atrophy. 

Cholesteatomata  may  appear  in  any  portion  of  the  body;  however, 
the  middle  ear,  the  pia,  and  the  urinary  tract  are  most  often  invaded. 

In  the  tympanic  cavity,  the  antrum  is  often  the  seat  of  tumors  vary- 
ing in  size  from  a  hazel  nut  to  a  hen's  egg,  and  the  bony  structure  is 
often  destro3'ed  as  the  process  develops  in  size.  The  growth  frequently 
provokes  a  chronic  otitis  media,  perforates  the  attic  and  extends  into 
the  cranial  cavity.  The  origin  of  cholesteatomata,  in  this  situation,  is 
ascribed  to  displacement  of  the  ectoderm  in  the  temporal  region  during 
embryonic  development  of  the  ear.  They  are  also  believed  to  occur 
sequentially  to  chronic  inflammatory  processes.  The  latter  perforate 
the  tj^mpanum,  and  the  proliferation  of  squamous  epithelium  occurs 
in  an  effort  to  replace  the  destroyed  cylindrical  epithelium,  and  thus 
gain  access  to  the  middle  ear.  In  another  class  of  cases  the  exfoliated 
epithelium,  together  with  thickened  pus,  forms  the  cholesteatoma 
{pseudocholesteatoma).  Borst^*  believes  that  the  epithelium  of  the 
middle  ear  is  capable  of  metaplasia  and  that  perforation  of  the  tyin- 
panum  is  not  necessary.  Similar  masses  are  found  in  cases  of  chronic 
otitis  media,  but  the  epidermal  sac  is  wanting  (KiimmeP''). 

Cholesteatomata  of  the  pia  are  round  or  nodular  tumors  which  grow 
very  slowly  and  do  not  provoke  s\Tnptoms  until  they  reach  a  certain, 
size.  Usually  they  are  located  at  the  hase  of  the  skull  within  the  pia, 
and  at  times  are  found  in  the  ventricles.  The  capsule  of  the  growth 
is  always  attached  to  the  pia  and  is  lined  with  several  layers  of  flat- 
tened epithelium.  Bostrom^*'  regards  these  tumors  as  epidermoids 
and  attributes  their  origin  to  displacement  of  the  ectoderm  during 
fetal  anlage  of  the  pia  (about  the  fourth  or  fifth  week).  Borst'* 
considers  them  as  endotheliomata. 

Occasionally,  cholesteatomata  are  found  in  the  bones  of  the  face  and 
skull,  especially  the  frontal,  the  occipital,  and  the  parietal  bones. 
Lexer^'  (quoted  b}'  Untermej'er^^)  found  one  in  the  orbital  cavity 
attached  to  the  sphenoid.  Borchardt^^  reports  an  extradural  choleste- 
atoma which  he  removed  from  the  posterior  cranial  cavity. 

So-called  cholesteatomata  of  the  urinary  passages  are  not  genuine 
tumors,  but  the  products  of  abnormally  situated  flat  epithelial  cells. 


1244 


TUMORS 


Masses  of  this  sort  are  found  behind  strictures  of  the  urethra,  in  the 
bladder,  the  ureters,  and  the  pelvis  of  the  kidney  (Briichenow*"). 
Conen*^  reports  a  cholesteatoma  of  the  navel. 

Adamantinomata  and  Follicular  Cysts  of  the  Jaws. —  Adaman- 
tinomata  are  benign  tumors  of  the  jaws,  which  occur  earlj^  in  life, 
grow  very  slowly,  and  reach  the  size  of  an  apple,  and  occasionally  that 
of  the  adult  fist.     They  are  encapsulated,  lie  in  the  substance  of  the 


Fig.  603. —  Cholesteatoma  of  the  Skull,  which  has  Ixvaded  the  Orbit. 

a,  Part  of  tumor  which  has  invaded  tlie  orbit;   1),  external  table  elevated  by 
tumor  mass;  c,  layer  of  bone,  remains  of  external  table. 


bone,  and  gradually  thin  it  out  until  only  a  shell  remains.  AVhen  the 
contents  of  the  'growth  becomes  cystic,  the  residual  bony  wall  imparts 
the  feeling  of  'parchment  craclding  to  the  palpating  finger.  In  the 
upper  jaw  the  process  often  extends  into  the  antrum  of  Highmore. 

On  section,  the  growth  presents  a  varying  picture.  Sometimes  that 
of  a  homogeneous,  yellow,  coarse  mass,  the  consistence  of  a  fibroma; 
or  again,  a  number  of  small  and  large  cysts  are  present  (therefore,  the 
name  multilocular  cystoma  of  the  jaw;    epithelioma  adamantinosum, 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1245 


cysticum).  The  entire  mass  is  readilj^  enucleated  from  its  bed,  unless 
the  booie  is  very  thin,  and  then  the  latter  is  likely  to  be  fractured 
(Fig.  604). 

Microscopically,  these  solid  tumors  are  seen  to  consist  of  fibrillary 
connective  tissue  with  a  network  of  interlofimj  narrow  and  broad 
columns  of  epithelial  cells,  so  that,  when  the  latter  are  dominantly 
present,  the  picture  is  not  unlike  that  of  carcinoma ;  however,  the 
presence  of  a  capsule  differentiates  it  from  a  malignant  process.  The 
epithelial  columns  contain  a  peripheral  layer  of  cylindrical  cells  within, 
which  are  flat  cells  arranged  concentrically  or  in  club  shaped  masses, 
so  that  epithelial  pearls  devoid  of  cornification  are  developed,  or  the 


Fig.  604. —  Multilocular  Cystoma  of  the  ^Mandible  (Adamantinoma). 
a,  Condyle;   &,  symphysis. 

interior  of  the  columns  are  filled  with  stellate,  interlacing  cells.  "When 
these  cellular  elements  disintegrate,  cysts  which  often  reach  consider- 
able size  are  formed  within  the  columns.  As  the  cysts  now  possess 
only  a  lining  of  c^'lindrical  epithelium,  the  picture  resembles  that  of  a 
cyst  adenoma.  The  histological  picture  is  t)Ccasionally  varied  by  the 
development  of  papillae  within  the  hdlow  spaces,  and  by  the  prolifera- 
tion of  connective  tissue  between  the  columns,  which  at  times  becomes 
ossified. 

The  form  and  the  arrangement  of  the  epithelium  indicate  that  these 
tumors  originate  from  the  enamel  organs,  hence,  the  name  adammi- 
tinoma.  Their  primary  location  suggests  that  they  spring  from  rests 
of  the  enamel  epithelium,  in  the  region  of  the  teeth,  which  remained 


1246  TUMORS 

unused  {debris  paradentaires  of  Malassez*').  It  is  not  unlikely  that 
inflammatory  processes  stimulate  the  latent  rest  into  active  prolifera- 
tion. 

The  dmgnosis  meets  with  considerable  difficulty.  Small,  solid 
tumors  resemble  osteomata.  The  cystic  form  presents  a  picture  not 
unlike  that  of  simple  maxillary  cysts,  while  the  process,  as  a  whole,  has 
many  characteristics  of  a  cetitrai  sarcoma. 

The  treatment  consists  in  enucleation  of  the  tumor.  Extensive  mul- 
tilocular  growths,  with  destruction  of  bone,  demand  resection  of  the 
affected  jaw  bone. 

Follicular  cysts  of  the  jaw  are  simple  cysts  arising  in  the  dental 
sacs  from  abnormally  placed  or  supernumerar}'  teeth.  They  occur  in 
any  portion  of  the  jaw. 

They  develop  mostly  in  early  life.  In  the  adult  they  are  usually 
situated  in  the  region  of  a  wisdom  tooth,  especially  in  the  loiver  jaw, 
where  they  slowl}-  cause  thickening  of  the  hone.  In  the  upper  jaw 
they  at  times  gi*ow  into  the  antrum  of  HighmOre. 

Cysts  of  this  nature  possess  a  flai  sa<^  wajl  lined  with  epithelium, 
which  is  derived  from  the  tooth  sac  and  may  contain  a  rudimentary  or 
fully  developed  tooth,  together  with  a  seromucous  fluid  and  a  few 
crj^stals  of  cholesterin. 

The  frequency  with  which  follicular  cysts  occur  helps  in  the  diag- 
nosis. However,  as  they  at  times  thin  out  the  corticalis,  parchment 
crackling  may  be  elicited,  so  that  central  sarcoma  must  also  be  taken 
into  account.  When  the  antrum  of  Highmore  is  invaded,  the  clinical 
picture  may  be  presented  in  that  cavity. 

The  treatment  consists  in  widely  opening  the  corticalis  and  excising 
the  sac  wall. 

Periosteal  cysts  of  the  jatc  hones  must  be  differentiated  from  both 
forms  of  the  genuine  epithelial  cysts  arising  within  the  bone.  Perio- 
steal cysts  are  the  result  of  inflammatory  processes  and  arise  in  con- 
nection with  p'eriostitis  at  the  roof  of  a  tooth.  The  alveolar  process 
disintegrates  and  a  turbid  mucoid  fluid,  which  contains  cholesterin, 
collects  beneath  the  periosteum  and  causes  the  formation  of  a  flat, 
fluctuating  swelling  upon  the  outer  aspect  of  the  jaw,  especially  in  the 
region  of  the  molar  and  bicuspid  teeth,  or  opens  into  the  maxillary 
sinus. 

It  is  a  question  whether  these  so-called  root  cysts  are  entirely 
dependent  upon  an  inflammatory  process.  The  presence  of  epithelium 
in  the  wall  of  the  cysts  (Malassez*-)  suggests  that  they  may  also  b^ 


TTJMORS  DEVELOPING  FROM  EPITHELIUM        1247 

due  to  displaced  epithelium.  It  is  possible  that  the  epithelial  rest 
must  be  present  before  a  cyst  will  develop  in  connection  with  perios- 
titis at  the  root  of  a  tooth. 

The  pain  and  rapid  development  -and  the  superficial  location  of  the 
process  differentiate  it  from  a  central  epithelial  cyst. 

The  treatment  consists  in  wide  exposure  of  the  lesion  and  curette- 
ment  of  the  cavity,  together  with  remo^^al  of  the  diseased  root  of  the 
tooth.  When  the  process  is  extensive  a  large  portion  of  the  anterior 
bon}'  wall  should  be  removed,  and  the  cavity  sho.uld  be  packed  and 
allowed  to  heal  from  the  bottom. 

Epithelial  Cysts  Developed  from  Normal  Embryonic  Anlage. — 
Cysts  may  develop  from  persisting  non-inv-oluted  rests  of  various 
embryonic  tissues  and  ducts  of  ectodermal  and  entodermal  origin. 
Thej^  are  most  often  developed  in  the  neck  and  the  floor  of  the  mouth, 
also  in  the  abdomen  {urachus)  and  from  the  vitelline  duct. 

Epithelial  cj'sts  of  the  neck  are  divided  into  those  occurring  in  the 
side  of  th£  neck  in  connection  with  the  hranchiul  clefts  {hranchiogenic 
cysts)  and  those  in  the  median  line  developing  from  the  thyroglossal 
duct.  Both  tumors  are  genetically  closely  related  to  congenital,  lateral 
and  median  cervical  fistulae. 

Branchiogemc  cysts  develop,  without  pain,  early  in  life  and  often 
are  congenital.  They  appear  in  the  region  lying  between  the  body 
of  the  lower  jaw,  the  inner  edge  of  the  sternomastoid  muscle,  and  the 
h^'oid  bone ;  they  are  located  beneath  the  platysma  and  extend  inward 
to  the  digastric  muscle.  The  growth  may  extend  dawnward  to  the 
clavicle  and  backward  beneath  the  sternomastoid  muscle  into  the  pos- 
terior triangle  of  the  neck.  The  tumor  is  flat  or  semiglobular,  is 
fairly  well  defined,  has  a  smooth  surface  and,  in  accord  with  its 
contents,  fluctuates,  or  is  of  a  doughy  consistence.  The  superimposed 
skin  is  normal  and  movable ;  the  tumor  itself,  being  attached  to  the 
deeper  structures,  is  fairly  well  fixed.  The  walls,  like  those  of  der- 
moids, are  smooth  without  and  have  a  white  lining,  or  their  inner 
surface  is  covered  with  a  grayish  red,  granular  membrane  resembling 
mucous  membrane.  Thej^  may  be  multilocular,  though  this  is  rare. 
The  contents  is  pa.sty,  mucoid  or  serous,  with  many  transitional  forms. 

The  symptoms  are  in  proportion  to  the  size  of  the  tumor. 

Like  the  congenital  hranchiogenic  fistulae,  the  inner  aspect  of  which 
opens  (when  complete)  into  the  tonsillar  cleft  and  the  outer  on  the 
neck  (at  any  point),  branchial  cysts  arise  in  connection  with  the 
second  embryonic  fold  (gill),  occasionallj'  the  first  or  the  third  (Hilde- 


1248 


TUMOKS 


brand,^^  Fritz  Koenig**).  "Weglowski*"^  contends  that  both  the  fistulae 
and  the  cysts  arise  in  connection  with  embryonic  rests  of  the  thjTnus 
duct  or  the  lateral  thyroid  duct. 

In  both  the  fistulae  and  the  cysts  the  epithelial  lining  is  not  always 
the  same.     The  inner  tissue  of  a  fistula  is  derived  from  the  entoderm 
and  consists  of  either  ciliated  cylindrical  epithelium  or  flat  epithelium 
with   lymphadenoid   tissue   supplied   with    follicles    (similar   to   the' 
pharyngeal  musoca),  while  the  outer  originates  from  the  ectoderm 


Fig.  605. —  Branchiogenic  Cyst. 


(neck  cleft)  and  is  supplied  with  flat  epithelium  and  papillae,  and 
at  times  with  skin  glands.  There  are,  however,  fistulae  which  are  lined 
with  cylindrical  epithelium  throughout,  which  indicates  that  they  are 
entirely  entodermal  in  origin. 

The  structure  and  the  contents  of  branchial  cysts  also  vary  according 
to  whether  they  develop  from  the  outer  or  the  inner  aspects  of  the 
cleft.  Cysts  lined  hy  skin  or  epidermis  contain  (as  is  to  be  expected) 
a  pasty  dermoid-Uke  substance  and  are  really  dermoids  or  epidermci.Ts. 

The  nvst  derived  from  the  entoderm  is  filled  with  a  mucoid  or  serous 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1249 


fluid  and  fluctuates  distinctly.  Its  lining  resembles  the  granular 
membrane  of  a  tuberculous  abscess,  although  the  granulations  are  firm 
and  cannot  be  "wiped  awa}',  as  they  consist  of  hjmph  follicles  lying 
beneath  a  layer  of  epithelium.  At  times  a  cyst  contains  several  varie- 
ties of  epithelium  and,  when  several  loculi  are  present,  each  may  be 
lined  by  a  different  form  of  epithelial  cell.  The  outer  wall  of  the 
cyst,  like  that  of  branchial  fistulae,  may  contain  lymphadenoid  tissue, 
striated  muscle  fibers,  or  cartilage. 
Thyroglossal  cysts  arise  from  rests  of  the  duct  of  that  name;   they 

never  reach  the  size 
attained  by  branchial 
cysts.  They  are  lo- 
cated in  the  median 
line  of  the  neck  in 
front  of  the  hyoid 
bone,  between  it  and 
the  larynx  or  in  the 
region  of  the  jugu- 
lum.  The  growth  is 
covered  with  normal 
skin,  is  round,  sharply 
outlined  and  fluctu- 
ates. While  it  may 
be  moved  in  all  direc- 
tions, its  attachments 
to  the  deeper  struc- 
tures are  apparent, 
especially  those  ex- 
tending to  the  hyoid 
bone,  which  consist  of 
very  clearly  palpable 
bands.  These  bands  are  remnants  of  the  thyroglossal  duct,  which  often 
communicates  with  the  surface  by  means  of  a  median  fistula  (Fig. 
606). 

In  this  situation  the  epithelial  lining  of  the  fistula  is  also  of  various 
kinds.  When  the  fistula  originates  from  the  lower  part  of  the  duct, 
the  epithelium  is  of  the  ciliated,  cylindrical  form;  when  from  the 
upper  part  {ductus  lingualis),  the  epithelium  is  similar  to  that  of  the 
mucosa  of  the  mouth.  At  times,  the  wall  of  a  thyroglossal  cyst  con- 
tains follicles  of  the  thyroid  gland. 


Fig.  606. —  Thtroglossal  Fistula. 


1250  TUMORS 

In  discussing  the  diagnosis,  the  conditions  which  must  be  taken  into 
account  are  already,  in  part,  taken  up  in  connection  with  dermoid  cysts 
in  this  location.  Large  fluctuating  cysts  are  readily  mistaken  for 
congenital  cystic  lymphangioniata,  and  differentiation,  even  with  the 
aid  of  the  microscope,  is  not  easily  made.  In  median  cysts  the  bands 
connected  with  the  h^-oid  bone  are  of  diagnostic  value.  As  a  rule, 
dermoid  cysts  are  superficially  located  and  are  freely  movable.  The 
nature  of  a  tuberculous  abscess  is  revealed  by  the  presence  of  enlarged 
contiguous  glands.  Unlobulated,  small  Upomata  closely  resemble 
thyroglossal  cysts. 

At  times,  a  number  of  small  cysts  develop  in  the  floor  of  the  mouth 
and  are  called  ranulae ;  they  originate  from  the  ductus  lingualis  (a 
part  of  the  thyroglossal  duct  extending  from  the  foramen  cecum  to  the 
hyoid  bone).  Some  of  these  cysts  are  lined  with  ciliated,  cylindrical 
epithelium  and  are  believed  to  dcveliop  from  rests  of  the  so-called 
Bochdalek's  follicles,  which  are  really  lateral  evaginations  of  the 
lingual  duct. 

Cysts  of  the  urachus  are  rare  tumors  developing  from  epithelial  rests 
of  the  embryonic  canal  connecting  the  bladder  with  the  allantois. 
When  the  canal  is  entirely  obliterated  (as  it  is-  normally),  it  forms  the 
middle  ligament  of  the  bladder.  When  the  entire  length  of  the  canal 
remains  patent,  it  is  responsible  for  urinary  fistula,  of  the  urachus. 
When  only  a  portion  of  the  duct  is  obliterated,  small  cysts,  the  size  of 
a  pea,  or  a  very  large  cyst,  containing  yellowish  fluid,  develop.  The 
presence  of  these  cj^sts  is  usually  manifested  in  childhood,  but  may  not 
appear  until  adult  life.  The  microscope  reveals  non-striated  muscle 
fibers  in  the  walls  of  the  cj'sts  and  a  lining  consisting  of  a  layer  or  layers 
of  flat  epithelium.  The  cj'sts,  at  times,  suppurate  or,  though  very 
rarely,  form  the  basis  of  carcinoma  (Lexer,**'  v.  Recklinghausen*'^). 

Cysts  of  the  vitelline  duct  develop  from  the  omphalomesenteric  duct 
which,  until  the  eighth  week  of  embryonic  life,  connects  the  intestinal 
canal  with  the  vitelline  sac.  When  its  communication  with  the  umbil- 
ical cord  remains  patent,  a  congenital  fistula,  which  discharges  mucus 
and  feces,  is  developed  after  the  cord  separates.  When  the  umbilical 
cord  closes,  a  blind  sac  communicating  with  the  lower  end  of  the  ilium 
is  established  {Meckel's  diverticulum) . 

When  the  intestinal  end  is  closed,  an  opening  remains  at  the  navel, 
the  mucous  membrane  lining  is  everted,  and  a  navel-vitelline  duct 
diverticidum  is  formed.  When  both  ends  are  obliterated,  a  vitelline 
duct  cyst   (enterocj^stoma)   develops.     The  walls  of  the  cyst,  of  the 


TUMORS  DEVELOPING  FROM  EPITHELIUM        1251 

fistulae,  and  of  the  diverticuli  contain  smooth,  intestinal  musculature 
in  regular  or  irregular  bands ;  the  inner  surface  is  lined  with  mucous 
membrane  which  corresponds  to  either  the  embryonic  or  fully  devel- 
oped intestinal  mucosa.  Cysts  of  this  sort  are  found  within  the 
abdominal  wall,  in  the  region  of  the  umbilicus,  in  front  of  the  peri- 
toneum, or  within  the  abdominal  cavity.  In  the  last  instance  they  are 
either  attached  to  the  parietal  peritoneum,  to  a  loop  of  the  gut,  or  to 
the  mesentery ;  or  they  may  lie  between  the  layers  of  the  latter.  The 
occasional  occurrence  of  multiple  enterocystomata  suggests  that  some 
of  these  tumors  may  develop  from  displaced  rests  of  the  intestinal 
glandular  embryonic  tissue  (Borst^^). 

The  treatment  of  congenital  epithelial  cysts  consists  in  complete 
extirpation  of  the  tumor,  which,  when  adhesions  are  present,  is  not 
always  easy. 

BIBLIOGRAPHY 

1.  RiBBERT.       Geschwiilstlehre,    Bonn,    1904,    and    Beitr.    z.    Ensteh.    d. 

Geschwiilste,  Bonn,  1906. 

2.  BURCKHARDT.     Beitr.  z.  klin.  Chir.,  Bd.  69,  1910. 

3.  Landau.     Zeitschr.  f.  Krebsfusch,  Bd.  12,  1913. 

4.  Lexer.     Alleem.  Chir.  ii,  Stuttgart,  1914. 

5.  DoRiXG.    Arch.  f.  klin.  Chir.,  Bd.  83,  1907. 

6.  KuTTXER.    Hndb.  d.  prakt.  Chir.,  Ed.  3,  Bd.  i. 

7.  Nasse.     Arch.  f.  klin.  Chir.  Bd.  44,  1892. 

8.  SCHIMMELBUSCH.     Arch.  f.  klin.  Chir.  Bd.  41,  1892. 

9.  KOENiG.     See  Schimmelbusch  No.  8. 

10.  Gierke.    Virchow's  Arch.  Bd.  170,  1902. 

11.  GoBEL.    Deutsch.  Zeitschr.  f.  Chir.,  Bd.  47,  1898. 

12.  Albrecht.     Chir.  Kone.  Verb.,  1905,  ii. 

13.  Beer.     Zeitschr.  f.  Heilkunde,  Bd.  25,  1904. 

14.  V.  Bergmaxn.     Chir.  Kong.  Verb.,  1893,  ii. 

15.  Hildebraxd.     Deutsch.  Zeitschr.  f.  Chir.,  Bd.  40,  1895. 

16.  HoLST.     T.  D.,  Leipzig,  1904. 

17.  SUDECK.     Virchow's  Arch.  Bd.  133,  1893. 

18.  Grawitz.    See  Stork  No.  19. 

19.  Stork.    Beitr.  z.  path.  Anat.  Bd.  43,  1908. 

20.  Kroxleix.     Beitr.  z.  klin.  Chir.,  Bd.  41,  1889. 

21.  V.  Bramaxn.     Arch.  f.  klin.  Chir.  Bd.  40,  1890. 

22.  Wilms.     In  Ziegler's  Beitr.,  1902.  xxxi. 

23.  Lanxeloxgue  et  Achard.     Traite  d.  eystes  congenitaux,  Paris,  1886. 

24.  Laxxeloxgue  et  Mexard.     Affect.  Congenit.,  Paris,  1891,  T.  i. 

25.  Wrede.     Beitr.  z.  klin.  Chir.,  Bd.  48,  1906. 

26.  Fraxke.     Deutsch.  Zeitschr.  f.  Chir.,  Bd.  40,  1895. 

27.  H.  Wolff.     Beitr.  z.  klin.  Chir.,  Bd.  48,  1906. 

28.  Chajes.     Berlin,  klin.  Woch.,  1907. 

29.  Kruger.    Arch.  f.  klin.  Chir.,  Bd.  91,  1910. 

30.  Dubreuilh.     Ann.  d.  dermat.  et  d.  syph.,  1907. 


1252  TUMORS 

31.  Garre.    Beitr.  z.  klin.  Chir.,  Bd.  ii,  1894. 

32.  Pels-Leusdek.     Deutsch.  med.  Woeh.,  1905. 

33.  Hesse.     Beitr.  z.  klin.  Chir.,  Bd.  80,  1913. 

34.  BoRST.     Die  Lehre  der  Geschwiilste,  Bonn,  1902. 

35.  KiJMMEL.     Haudb.  d.  prakt.  Chir.,  Ed.  4,  i. 

36.  BoSTROM.    Zentrbl.  f.  Allge.  Path.,  Bd.  8,  1897,  with  lit. 

37.  Lexer.     See  Untermeyer  No.  38. 

38.  Untermeyer.     Deutsch.  Zeitschr.  f.  Chir.  Bd.  81,  1906. 

39.  Borchardt.     Chir.  kong.  Verh.,  1905,  ii. 

40.  BrIjchenow.    Prager  med.  Woeh.,  1898. 

41.  CoNEN.    Beitr.  z.  klin.  Chir.,  Bd.  58,  1908,  1909. 

42.  Malassez.     Arch,  de  physiol.,  1885. 

43.  HiLDEBRAND.     Arch.  f.  klin.  Chir.,  Bd.  xlix,  1894. 

44.  Fr.  Koenig.     Arch.  f.  klin.  Chir.,  Bd.  Ii,  1896. 

45.  Weglowski.     Zentrbl.  f.  Chir.,  1908. 

46.  Lexer.     Arch.  f.  klin.  Chir.,  Bd.  57,  1898. 

47.  V.  Recklinghausen.    Deutsch.  med.  Woeh.,  1902,  No.  34. 


CHAPTER  XVII 
CAECINOMATA 

Borst^  saj's  that  the  term,  cancer  dates  back  to  Galenus,  and  is  based 
on  the  fact  that  many  cancers  of  the  breast,  with  radially  arranged, 
dilated  veins,  present  the  general  form  of  a  sea  crab. 

Carcinomata,  or  cancers,  are  tumors  composed,  essentially,  of 

EPITHELIAL  CELLS  SUPPORTED  OR  SURROUNDED  BY  A  VASCULAR  STROMA, 
WHICH    THEY    EXACT    FROM    THE    NEIGHBORING    TISSUES     (MacCallum-) . 

Lexer^  says:  *'The  conception  of  tumors  termed  carcinomata  applies 
to  Dialignant  epithelial  growths  dominantly  characterized  hy  infiltrat- 
ing extension,  in  the  course  of  ivhich  the  invaded  tissue  is  destroyed." 

In  a  general  wa}',  these  tumors  are  composed,  in  varj^ing  propor- 
tions, of  parenchyma  and  stroma.  The  former  consists  of  epithelial 
cells  which,  in  accord  with  their  origin  —  from  the  skin,  the  mucosa, 
the  glandular  organs ;  from  residual  embryonic  tissue ;  or  from 
benign  fibro-epithelial  tumors  and  cysts  lined  with  epithelium  —  not 
alone  vary  in  character  but,  despite  their  rapid  proliferation,  retain 
certain  characteristics  of  the  parent  cell,  such  as  the  capacity  to 
eornify  (in  flat  epithelial  cancer)  and  to  produce  mucus,  bile  or  col- 
loid (in  cancer  of  the  gastro-intestinal  canal,  the  gall  bladder  or  the 
thyroid  gland).  The  stroma,  or  hasal  structure,  represents  a  network 
of  supporting  columns,  consisting,  in  part,  of  newly  formed  connec- 
tive tissue  which  contains  a  liberal  supph^  of  blood  vessels,  and,  in  part, 
of  the  invaded  tissue,  i.  e.,  preexisting  connective  tissue,  muscle  fibers, 
portions  of  organs,  etc. 

When  stroma  predominates,  the  carcinoma  is  hard  and  tends  to 
shrink;  when  parenchyma  is  dominant,  the  tumor  is  soft.  The  first 
form,  which  is  called  scirrhus,  never  reaches  the  extensive  growth  of 
the  latter,  which  is  called  medullary  carcinoma.  The  form  in  which 
neither  element  predominates  is  called  carcinoma  simplex. 

Little  is  known  of  the  histogenesis  of  carcinomata.  The  conception 
of  Virchow,  that  they  originate  from  connective  tissue,  has  been  dis- 
proved by  the  work  of  many  observers,  chief  among  whom  may  be 

1253 


1254  TUMORS 

mentioned  Hauser/  who  proved  their  epithelial  origin,  and  Koster,^ 
who  showed  that  certain  tumors,  classified  as  carcinomata,  develop 
from  the  epithelium  of  the  lymph  vessels  and  are,  therefore,  of  a  con- 
nective tissue  nature.  For  this  reason  these  tumors  are,  at  times, 
classified  as  sarcomata ;  and,  at  other  times,  they  are  separated  into  a 
group  by  themselves  {endothelioma).  Rib.bcrt*'  has  shown  that  con- 
nective tissue  plays  an  important  role  in  the  development  of  carcinoma. 
He  insists  that  "proliferation  of  connective  tissue  is  the  cause  which 
provokes  the  unbridled  proliferation  of  epithelial  cells  and  their 
invasion  of  the  tissues." 

According  to  generally  accepted  views,  proliferation  in  squamous 
cell  carcinoma  begins  in  the  germinal  layer  of  the  epidermis,  and  in 
the  mucosa  in  the  corresponding  pavement  epithelial  cells.  At  the 
point  where  the  process  begins  the  cells  multiply.  The  new  cells, 
however,  show  faulty  development  as  compared  to  the  normal  cells, 
and  irregular  so-called  pathological  karyokinetic  figures;  changes 
which  are  explained  on  the  ground  of  excessive  growth. 

The  layer  of  proliferating  epithelial  cells  soon  crowds  the  superim- 
posed normal  cells  upward  and  causes  them  to  exfoliate,  so  that  the 
newly  developed  cells  are  exposed.  At  the  same  time,  cellular  pro- 
liferation (like  that  of  embryonic  development)  extends  radially  in 
all  directions  and  successively  breaks  through  the  natural  limitations 
of  the  contiguous  tissues  in  the  form  of  cone-like  projections.  Gradu- 
ally, by  the  budding  of  these  (mostly)  solid  cell  cones,  a  many 
branched,  intercommunicating  "root  work"  (the  several  divisions  of 
which  emanate  from  the  site  of  the  primary  area  of  proliferation)  is 
formed  which  bears  some  resemblance  to  the  root  of  a  plant.  Section 
of  the  process  divides  some  cell  columns  transversely,  and  others 
obliquely,  which,  under  the  microscope,  causes  them  to  appear  as 
separate  islands  of  epithelium  or  alveoli.  Genuine  alveolar  formation 
is  the  outcome  of  constriction  and  separation  of  a  group  of  cells  from 
a  cone-like  process.  However,  according  to  Petersen,^  true  alveolar 
growth  need  not  occur  in  connection  with  columnar  proliferation,  but 
maj^  primarily  take  on  the  form  of  isolated  epithelial  islands.  Hauser* 
and  Petersen'^  have  shown  that  proliferation  of  carcinoma  may  begin 
simultaneously  at  several  adjacent  points. 

Many  authors  are  of  the  opinion  that  the  cells  of  the  glands,  for 
example,  in  cancer  of  the  skin,  those  of  the  hair  follicles,  the  sebaceous 
glands,  and  perhaps  also  the  sweat  glands,  are  concerned  in  prolifera- 
tion (Borst^).    Ribbert,^  however,  holds  that  this  observation  is  illu- 


CARCINOMATA 


1255 


sionaiy,   and  that  the  cancer   epithelial   cell   migrates  through  the 
glands,  giving  the  impression  that  it  grows  from  it. 

While  the  cellular  projections,  like  a  fungiform  mycelium,  invade 
the  skin  and  subcutis,  or  submucosa,  and  destroy  the  normal  tissues  by 
pressure,  and  perhaps  also  by  the  action  of  proteolytic  ferments,  the 
connective  tissue  is  not  idle,  but  in  much  the  same  manner  as  obtains 
in  mild  inflammatory  processes,  proliferates  and  soon  forms  a  vascular 
granulation  tissue.  That  is,  both  destruction  and  proliferation  occur 
in  the  domain  of  the  primaiy  invading  epithelial  projections,  which 
are  thus  surrounded  with  the  remnants  of  the  original  tissue  and 
newly  formed  connective  tissue.  Where  the  tumor  grows  heyond  the 
surface  of  the  lodij  it  contains  only  proliferated  connective  tissue, 
plentifully  supplied  with  blood  vessels;  the  skin  or  mucosa  is  infil- 
trated; and  some  of  the  pre- 
existing connective  tissue 
takes  part  in  the  structure 
of  the  stroma. 

Reactive  proliferatio^i  of 
the  invaded  tissues  takes 
place  in  all  instances.  This 
is  particularly  noticeable  in 
connection  with  the  develop- 
ment   0  f    metastases,    and 

Fig.  607.—  Metastatic  Foci  ix  the  Axillary    especiallv,  in  those  forming 
Lymph  Nodes  Secondary  to  a  CarcixoMxV    . 
OF  THE  Breast.  ui  the  bone. 

A    similar    condition    of 

affairs  prevails  in  cylindrical  epithelial  cancer  which,  according  to 

Hauser,*  develops  in  all  mucous  membranes  covered  by  cjiindrical 

epithelium  and  when  embryonic  rests  contain  cells  of  this  kind.     In 

these  situations,  however,  the  cancer  cones  are  not  solid,  but  possess  a 

lumen   (which  causes  them  to  bear  some  resemblance  to  glandular 

structures)    arranged  in  the  form  of   a  number   of  communicating 

tuhules. 

An  analogous  condition  of  affairs  may  be  recognized  in  glandular 
epithelial  carcinoma.  Here  the  epithelial  cones  are  at  times  solid,  and, 
at  others,  they  contain  a  small  lumen.  The  normal  glands  are  en- 
gulfed and  strangulated  by  the  cancer  cones  which  invade  their 
structure  in  all  directions. 

The  prevailing  opinion  regarding  the  development  of  carcinoma  is 
attacked  by  Eibbert,"  who  insists  that  epithelial  proliferation  does  not 


1256  TUMORS 

play  the  important  role  in  the  process,  but  that  subepithelial  connec- 
tive tissue  does.  Like  Albrecht,'-'  he  compares  the  phenomenon  with 
that  of  embryonic  gland  development.  But,  unlike  Albrecht,''  he  does 
not  ascribe  the  primary  impetus  in  the  new  formation  to  the  epithelial 
elements,  but  is  of  the  opinion  that  the  resistance  of  the  connective 
tissue  is  lessened  and  the  epithelial  cells  are  thus  permitted  to  pro- 
liferate ad  libitum,  break  through  the  basement  membrane,  and  invade 
the  contiguous  tissues;  a  condition  of  affairs  which  does  not  obtain 
when  the  normal  relationship  between  cell  and  interstitial  tissue 
prevails. 

Borst*  admits  that  active  inflammatory  connective  tissue  prolifera- 
tion may  be  attended  with  separation  and  isolation  of  groups  of  epithe- 
lial cells  and  that  these  may  assume  independent  proliferation;  how- 
ever, he  claims  that  the  initiative  in  the  entire  process  of  proliferation 
origi7iates  with  the  epithelial  cell.  At  this  time  this  is  the  conception 
maintained  by  the  majority  of  pathologists. 

Oil  the  other  hand,  considerable  differences  prevail  with  regard  to 
the  extension  of  carcinomata.  On  the  one  side  (Ribbert,®  Borst,^  and 
others),  the  view  is  taken  that  the  small,  somewhat  altered  (perhaps 
separated  from-  their  attachments)  groups  of  epithelial  cells  which 
form  the  origin  of  the  primary  carcinomatous  zone,  grow  from  within 
themselves  as  the  result  of  an  intrinsic  force,  and  invade  the  contigu- 
ous normal  epithelial  cells  of  the  gladular  tissues  and  destroy  them. 
On  the  othsr  side  (Hauser,*  Beneke,^°  and  others),  it  is  maintained 
that  the  epithelial  cells  contiguous  to  a  carcinoma  are  converted  into 
cancer  cells,  and  contribute  to  the  growth  of  the  tumor  by  apposition. 
This  transformation  of  normal  epithelium  is  explained  largely  on  the 
ground  that  an  infective  irritation  arises  at  the  point  of  origin  of  the 
growth.  This  finds  some  support  from  microscopical  observation  of 
the  behavior  of  the  surface  and  glandular  cells  at  the  edge  of  the 
carcinomatous  proliferation.  The  glandular  cells  are  always  found  in 
the  process  of  multiplication  and  may  be  ohserved  in  the  act  of  being 
converted  into  cancer  cells.  However,  according  to  Ribbert,^  this  is 
to  be  regarded  as  a  reactive  proliferation  similar  to  that  occurring  in 
connective  tissues  which  are  being  invaded  by  carcinoma  cells,  and  not 
as  a  transformation  of  normal  epithelial  cells  into  carcinoma  cells. 
Similar,  even  atypical  (i.  e.,  extending  into  the  deeper  tissues  to  an 
abnormal  extent)  epithelial  proliferation  which  may  be  produced 
experimentally  (Fisher,^^  with  scarlet  oil.  Wacker^^  and  Schmincke,^^ 
with  various  soluble  liquids)    is,  at  times,  seen  in  connection  with 


CARCINOMATA  1257 

chronic  inflammalory  processes,  especially  in  skin  tuberculosis.  This 
does  not,  mean  that  cancer  has  developed,  nor  that  it  will  necessarily 
follow.  By  the  same  token,  it  has  as  yet  not  been  possible  to  provoke 
tumor  growth  by  the  implantation  of  artificially  produced  at}^i)ical 
epithelial  proliferation ;  in  each  instance  the  implant  has  degenerated 
(v.  Hausemann,^*  v.  Lamezan^'').  Again,  it  is  noteworthy  that  groups 
of  cancer  cells  grow  into  the  epithelium  at  the  edge  of  the  growth  and 
surround  the  normal  gland  tubules,  so  that  normal  glandular  alveoli 
may  be  mistakeil  for  the  newly  formed  alveoli  of  carcinoma. 

Carcinoma  extends  almost  exclusively  hy  infiltration.  On  the  skin 
and  mucous  membranes  it  extends  on  the  surface  and  into  the  deeper 
tissues,  and  at  times  is  elevated  ahove  the  surface.  In  organs,  it 
spreads  in  all  directio^is.  As  the  tumor  enlarges,  the  carcinoma  cells 
displace  the  tissues  and  invade  the  delicate  lymph  spaces  and  vessels 
by  means  of  which  metastases  are  formed.  The  destruction  of  the 
basal  membranes  of  the  invaded  tissues  is  due  to  interference  with 
nutrition,  to  pressure,  and  the  action  of  proteolytic  ferments. 

The  invasion  of  the  tissues  in  the  immediate  vicinity  of  the  primary 
focus  is  atfected  in  part  by  separation  of  carcinoma  cells,  which  are 
spread  by  the  lymph  stream,  and  in  part  by  the  amebic  motility  of  the 
cells  themselves.  The  result  is  the  formation  of  small  (rarely  larger 
than  a  bean),  red,  firm  n'odules  iii  a  wide  circle  about  the  original 
focus.  This  is  often  seen  in  carcinoma  of  the  breast  (Fig.  608)  and  is 
called  local  metastatic  formation  {disseminatio).  As  each  of  the 
nodules  is  surrounded  by  additional  proliferation  within  the  lymph 
vessels,  the  skin  may  be  almost  symmetrically  infiltrated,  so  that  the 
local  picture  ma^^  be  not  unlike  that  of  erysipelas. 

More  frequently',  however,  the  separated  cells  do  not  remain  in  the 
lymph  vessels,  but  are  deposited  in  the  nearest  lymph  nodes,  in  which, 
in  the  majority  of  carcinomata  the  first  (IjTuphogenous)  metastases 
are  found.  At  first  the  cortical  sinus,  then  the  follicles,  and,  finally, 
the  medullary  substances  are  invaded  hj  the  cell  mass  until  the  entire 
lymph  node  is  involved.  The  invasion  of  lymph  n'odes  may  he  recog- 
nized hy  their  nodular  increase  in  size.  Section  of  small,  recently 
invaded  glands  reveals  within  their  gri-ayish  red  tissue,  yellowish  and 
white,  often  confluent,  foci.  As  the  progressivelj'  infiltrated  gland 
enlarges,  its  capsule  ruptures,  and  neighboring,  similarly  affected 
nodes,  become  adherent  to  one  another  and  form  a  large  nodular  tumor 
from  which  the  adjacent  tissues  are  also  invaded.  When  the  super- 
imposed skin  is  also  infiltrated  and  destroyed,  a  nodular  mass  pro- 


1258 


TUMORS 


trudes  from  it  which,  at  its  center,  is  usually  the  seat  of  a  deep,  crater- 
like, putrefactive  ulcer.  Extension  of  the  process  along  the  perivascu- 
lar lymph  spaces  of  large  blood  vessels  involves  the  danger  of  destruc- 
tion of  the  vessel  wall,  which,  when  arteries  are  invaded,  is  attended 
with  profuse  and,  at  times,  fatal  hemorrhage.  In  the  veins,  a  similar 
occurrence  is  more  likely  to  be  followed  by  thromhosis  which  gives 
origin  to  the  distribution  of  tumor  cells  in  the  general  blood  stream. 


Fig.  608. —  Disseminating  Carcinoma  of  Breast. 


It  is  certain  that  occasionally  a  carcinomatous  lymph  node  undergoes 
spontaneous  regression. 

When  lymphatic  nodes,  which  normally  do  not  receive  lymph  from 
the  carcinomatous  zone,  are  affected,  it  would  seem  necessary  to  assume 
that  the  cancer  elements  are  conveyed  to  them  by  retrograde  circula- 
tion. However,  it  is  more  probable  that  the  carcinoma  cells  proliferate 
along  the  lumen  of  the  lymph  vessels,  forming  a  continuous  mass,  than 
that  the  lymph  stream  becomes  reversed  as  the  result  of  the  occlusion 


CARCINOMATA  1259 

of  one  of  the  larger  lymphatic  channels  and  that  the  cells  are  carried 
to  the  nodes  by  a  collateral  lymph  stream.  As  a  result  of  this  carci- 
nomatous proliferation. along  the  lumen  of  the  lymphatic  vessels,  in 
carcinomata  of  the  peritoneum  white  cords  are  formed  which  may 
frequently  be  seen  extending  from  one  diseased  lymph  node  to  another 
beneath  the  transparent  membrane.  These  cords  correspond  to  lymph- 
atic vessels  filled  with  carcinoma  cells.  A  similar  condition  of  affairs 
obtains  beneath  the  visceral  pleura,  associated  with  metastatic  foci  in 
the  lungs. 

Hematogenous  metastases  are,  in  part,  secondary  to  invasion  of  the 


Fig.  609. —  Metastatic  Foci  in  the  Liver,  Secondary  to  a  Carcinoma  of  the 

Eectum. 

lymph  nodes,  the  cancer  cells  gaining  access  to  the  lymph  stream 
through  the  thoracic  duct.  In  a  certain  number  of  instances,  however, 
the  process  enters  the  blood  directly  through  the  wall  of  a  vem.  This 
may  occur  in  connection  with  a  primary  carcinoma  or  from  a  second- 
arily invaded  lymph  node. 

The  first  organs  to  be  invaded  through  the  general  blood  stream  and 
the  portal  sj^stem  are  the  liver  (Fig.  609)  and  the  lung  in  accord  with 
the  location  of  the  primary  focus.  From  these  situations  the  process 
is  conveyed  to  the  various  organs,  the  skin  and  the  hones. 

A  peculiar  tendency  to  the  formation  of  hone  metastases  is  observed 
in  connection  with  carcinomata  of  the  breast  (Fig.  610),  the  thyroid 


1260 


TUMORS 


gland,  and  the  prostate.  The  bone  lesion  usually  develops  at  the  site 
of  greatest  vascularity,  namely,  the  ends  of  the  long  tubular  hones 
or  the  vertebrae.  The  bone  is  either  destroyed  and  a  spontaneous 
fracture  (usually,  at  the  neck  of  the  femur)  or  a  kyphos  develops,  or 
it  is  stimulated  to  the  formation  of  new  bone  {osteoplastic  carcinoma). 
From  the  foreg-oing,  it  is  apparent  that  carcinoma  first  forms 

METASTASES  BY  WAY  OF  THE  LYMPH  NODES,  while  in  SARCOMA  HEMATO- 
GENOUS DISSEMINATION  IS  DOMINANT.  This  is  explainable  on  the  basis 
of  the  peculiarities  of  these  two 
classes  of  tumors,  also,  perhaps, 
on  the  ground  that  cancer  cells 
are  larg-ely  destroyed  in  the 
blood  stream. 

In  the  metastatic  nodules,  the 
class  of  cell  of  the  primary 
tumor  is  preserved.  However, 
the  arrangement  of  the  cells,  the 
structure  of  their  columns  or 
their  peculiar  characteristics, 
such  as  the  formation  of  horny 
substance  or  mucus,  may  be  lost 
in  the  metastases.'  This  may  be 
due  to  the  rapidity  of  the  pro- 
liferation or  the  result  of  a 
greater  tendency  toward  disin- 
tegration. 

Other  peculiarities  of  exten- 
sion of  some  carcinomata  are 
attributable  to  implantaHon  or 
accidental  transplantation  of 
cells.  These  so-called  implanta- 
tion carcinomata  occur  upon 
apposed    surfaces    of    lips,    the 

tongue  and  the  cheek,  the  labia,  the  inner  side  of  the  thigh,  or  the 
vocal  cords. 

An  attempt  has  been  made  to  account  for  the  occurrence  of  multiple 
cancer  in  the  digestive  tract,  the  air  passages,  and  the  urinary  pas- 
sage>s,  on  the  theory  of  the  transplantation  of  carcinoma  cells  from  a 
primary  tumor  situated  at  a  higher  level  (for  instance,  carcinoma  of 
the  tongue  and  esophagus,  the  latter  and  the  stomach;   the  pharynx, 


Fig.  610. —  Secondary  Xodule  from  a 
Tumor  of  the  Breast,  Involving 
Upper  End  OF  Femur  and  Producing 
a  Pathologiqal  Fracture. 


CARCINOMATA  1261 

the  tongue  and  the  larynx;  the  kidney  and  the  bladder).  It  is,  how- 
ever, difficult  to  be  certain,  that  so-called  inoculation  cancer  is  present. 
First,  the  condition  may  be  one  of  simultaneous,  multiple  carcinomata 
in  which  the  foci  develop  independentlu  of  each  other ;  again,  lympho- 
genous dissemination  against  the  lymph  stream  is  possible,  but  is 
susceptible  of  proof  only  when  the  communicating  lymph  vessels 
between  the  primary  and  secondary  tumors  are  filled  with  proliferative 
carcinoma  cells. 

Macrascopically  (Fig.  611),  the  sectioned  carcinoma  presents  a 
grayish  red,  somewhat  trmislucent ,  tissue  which,  despite  its  apparently 
clearly  defined  borders,  is  firmly  attached  to  the  surrounding  tissues 
and,  until  hemorrhage,  necrosis,  and  softening  occur,  is  smooth  and 
regular  in  appearance. 

It  has  two  important  peculiarities :  First,  when  the  stroma  is  mark- 
edly developed,  the  naked  eye  discerns  yellowish  white  epithelial  rests, 


Fig.  611. —  Macroscopic  Appearance  of  Sectioned  Carcinoma  of  the  Breast. 

which  lie  cl'ose  together  in  round  foci;  these  may  be  expressed  by 
lateral  pressure  with  the  fingers,  and  resemble  comerlo-UTie  7nasses  or 
vermicelli.  Second,  a  white,  milky  juice,  the  so-called  cancer  milk, 
which  consists  of  cell  elements  and  fat,  may  be  expressed  from  the 
sectioned  surface  with  the  knife  (especially  in  soft  cancer). 

Especial  characteristics  are  imparted  to  the  process  by  excessive  vas- 
cularity which  gives  a  dark  appearance  to  the  growth.  In?  carcinomata 
of  mucous  membranes  or  of  organs,  liberal  production  of  mucous  by 
the  cancer  cells  causes  the  tissue  to  assume  a  soft,  colloid,  glassy  con- 
sistence (colloid  carcinoma),  and,  finally,  the  occurrence  of  regressive 
changes  are  attended  with  distinguishing  landmarks.  Of  these,  atro- 
phy and  necrosis  play  an  important  role,  partly  a.s  a  result  of  the 
meager  nutrition  of  the  rapidly  proliferating  degenerating  tissues, 
and  partly  because  of  the  obliteration  of  important  vessels  from  pres- 
sure of  the  tumor  mass,  or  as  the  result  of  obstruction  of  their  lumen 


1262  TUMORS 

by  invading  projections.  Degeneration  of  cells  is  followed  by  soften- 
ing. In  closed  nodules,  the  absorption  of  the  fluid  contents  and  the 
collapse  and  shrinkage  of  the  softened  area  is  followed  by  the  appear- 
ance of  the  cancer  navel,  while  disintegration  of  the  infiltrated  skin 
and  mucous  membrane  is  succeeded  by  the  establishment  of  an  ulcer. 
Softening  of  the  interior  of  a  tumor  is  attended  by  bleeding  and  the 
formation  of  cysts,  which  must,  however,  not  be  mistaken  for  the 
hollow  spaces  of  true  cystic  carcinomata.  Occasionally,  calcification 
of  the  tumor  mass  is  observed. 

As  a  rule,  carcinoma  occurs  after  the  fortieth  year  of  life,  usually 
between  fifty  and  sixty.  It  does,  however,  occur  in  early  life,  espe- 
cially between  twenty  and  thirty,  while  children  are  rarely  affected. 
Occasionally,  a  child  is  visited  by  a  congenital  carcinoma,  especially  in 
connection  with  a  teratoid  mixed  tumor. 

The  female  sex  is  favored  over  the  male  in  the  proportion  of  six  to 
four,  which  Borst^  associates  with  the  frequent  occurrence  of  carcinoma 
in  the  female  genitals  and  breast. 

The  frequency  of  the  seat  is  variously  estimated.  Borst^  arranges 
it  in  the  following  order:  Skin,  stomach,  gut  (rectum),  uterus,  breast, 
esophagus,  ovaries,  gallbladder,  pancreas,  lung,  urinary  bladder, 
larynx,  liver,  thyroid  gland,  tongue,  kidney,  and  prostate. 

As  a  rule,  careinoma  appears  singly.  Multiple  carcinoma,  i.  e.,  each 
focus  developing  independently  or  at  short  intervals,  is  comparatively 
rare.  At  times,  it  is  possible  to  recognize  the  fact  that  the  growths 
developed  upon  a  similar  pathological  base,  such  as  leukoplakia  in  the 
mouth  and  tongue ;  on  top  of  a  seborrheic  skin  ;  xeroderma  pigmento- 
sum ;  skin  tuberculosis ;  chronic  eczema ;  in  both  breasts  after  double 
mastitis,  and  on  the  mucosa  of  the  gut  in  connection  with  polyposis. 
When  carcinomata  of  this  sort  develop  in  the  same  kind  of  tissue,  the 
structures  of  the  growths  are  similar  in  character.  When  they  develop 
in  different  tissues,  each  exhibits  the  structural  characteristics  peculiar 
to  its  origin. 

An  effort  has  been  made  to  diagnosticate  carcinoma  hy  means  of  the 
biochemical  differences  between  cancer  and  normal  cells.  For  the  pur- 
pose, various  serological  methods  (precipitin  hemolysin  reaction,  com- 
plement binding)  have  been  employed.  However,  none  of  these  has 
proved  of  sufficient  certainty  to  make  it  practicable.  The  dialyzing 
test  of  Abderhalden^''  would  seem  to  hold  out  some  hope  in  this  con- 
nection. It  is  based  on  the  assumption  that  the  circulation  is  invaded 
by  certain  incompletely  destroyed  proteins,  which  cause  the  formation 


CARCINOMATA  1263 

of  specific  ferments  and  these  filially  complete  the  destruction  of  the 
proteins  mentioned  (Apolant^'). 

From  a  clinical  standpoint  it  is  desirable  to  arrange  carcinomata  in 
accord  with  their  origin;  the  skin,  mucous  membranes,  and  glandular 
organs. 

Carcinomata  of  the  Skin. —  As  most  carcinomata  of  the  skin  develop 
from  the  surface  epithelium,  they  are  usually  composed  of  squamous 
cells.  Occasionally,  carcinomata  in  this  situation  spring  from  the 
glandular  elements  and  are  composed  of  cylindrical  epithelium. 

Skin  cancer  grows,  mostly,  in  the  form  of  solid  cones  which  spread 
out  like  the  roots  of  a  plant.  The  new  formation  is  composed  of  flat 
epithelial  cells  possessing  oval  nuclei.  Their  origm  is  indicated  by 
the  presence  of  protoplasmic  bridges  and,  above  all,  by  the  develop- 
ment of  cornification,  which  produces  a  typical  picture  and  yet  is 
absent  in  many  carcinomata,  especially  those  of  the  skin  of  the  face. 
The  young  cubical  or  cylindrical  cells  correspond  to  the  germinal 
layers  of  the  epidermis  and  occupy  the  periphery  of  the  down 
growths,  while  the  older,  flat,  comified  cells  are  found  in  the  center  in 
the  form  of  clul)  shaped  enlargements  of  the  cones,  in  which  they  form 
the  concentrically  arranged  globular  and  oval  bodies,  the  so-called 
cancer  or  horny  pearls.  When  only  a  part  of  a  cell  comifies,  while 
the  remainder  undergoes  hyaline  or  fatty  degeneration,  a  picture  is 
presented  which  has  often  been  mistaken  for  a  parasite  (Borst^).  At 
times,  multinuclear  giant  cells  are  found  in  squamous  cell  carcinoma; 
they  lie  between  the  stroma  and  the  epithelium  and  originate  from 
the  connective  tissue  (Petersen'^). 

Carcinomata  originating  in  the  sebaceous  glands  are  characterized 
by  the  presence  of  broad,  nodular,  thickened,  often  glandular,  flat 
epithelial  cords,  and  by  the  presence  of  fatty  metamorphosis. 

The  skin  (especially  that  of  the  face)  is  not  infrequently  the  seat  of 
cancer  which  presents  the  form  and  follows  the  clinical  course  of  flat 
carcinoma,  and  is,  occasionally,  attended  with  the  formation  of  nodular 
tumors,  but  does  not  correspond  in  structure  to  the  usual.  The  cell 
columns  are  nan-ow  and  pointed  and  often  possess  a  lumen.  The  cells 
themselves  are  long  and  narrow.  The  l^Tuph  spaces  are  arranged  in  a 
fine  network  and  correspond  to  the  delicate  columns.  Cornification  is 
absent  or  is  present  to  a  very  slight  degree.  As  the  structure  of  the 
cones  closely  resembles  glandular  structure,  Kromprecher^^  calls 
growths  of  this  sort  glandlike  superficial  epithelial  cancer,  or  basal  cell 
cancer.     His  view  that  these  carcinomata  spring  from  basal  cells,  i.  e., 


1264 


TUMORS 


the  cylindrical  cells  of  the  stratum  Malpig-hii,  while  horny  cancer 
develops  from  the  prickle  cells,  has  been  attacked  by  many  authors. 
V.  Hansemann^*  and  Ribbert®  do  not  consider  a  separation  into  basal 
and  prickle  cell  carcinoma  as  possible.  Ribbert®  regards  these  ques- 
tionable tumors  as  nan-comified  skin  carcinoinata;  Borst^  classifies 
them  with  the  endotheliomata.  According  to  Borrmann/**  non-corni- 
fied  carcinomata  originate  in  the  corium,  and  he  calls  them  corium 
carcinomata.  He  considers  that  they  spring  from  displaced  multiple 
epithelial  groups  or  from  vagrant  hair  or  gland  elements.     Conan 


Fig,  612. —  Squamous  Epithelial  Carcinoma  Showing 
Extensive  Cornification,  Invasive  Growth  of 
Epithelium,  and  Inflammatory  Reaction. 

(quoted  by  Borst^)  insists  that  they  arise  in  connection  with  the  skin 
glands,  believing  that  the  latter  are  invaginated  basal  cells  of  the 
epidermis. 

Shin  cancer  occurs  most  often  on  the  face,  less  frequently  on  the 
head  and  neck,  the  ear,  the  external  auditory  canal,  the  external 
genitals,  the  limbs  and  the  navel. 

It  originates  in  perfectly  normal  skin  or  in  skin  which  is  the  seat  of 
pathological  processes.  It  also  develops  at  the  site  of  congenital  or 
acquired  anomalies  of  the  skin ;  in  the  region  of  benign  fibro-epithelial 


CARCIXOMATA  1265 

proliferations,  such  as  warts,  papillomata,  cutaneous  horns,  hj-per- 
trophied  hair  follicles;  in  connection  with  adenomata  of  the  skin 
glands,  atheromata,  and  dermoid  cysts.  At  times,  it  finds  origin  in 
areas  of  skin  which  have  been  subjected  to  chronic  inflammatory  irrita- 
tion, such  as  occurs  from  frequent  attacks  of  erysipelas,  from  chronic 
eczema  of  the  scrotum,  and  on  the  limbs  (chimney  sweeps  or  workers 
in  paraffin  and  other  tar  products)  ;  occasionally  in  concert  with 
psoriasis,  chronic  ulcers  (s^-philitic,  tuberculous  or  varicose)  and  X-ray 
ulcers.  According  to  Kaposi,^°  the  congenital  atrophy  of  the  skin 
(xeroderma  pigmentosum)  which  is  attended  with  a  peculiar  disturb- 
ance of  pigmentation  has  been  the  site  of  carcinoma  in  young  persons 
in  several  instances.  In  old  people,  seborrhea  senilis  on  the  temples, 
the  forehead  and  the  bridge  of  the  nose,  is  often  followed  by  the  devel- 
opment of  skin  cancer. 

Senile  sehorrhea  (usually  the  result  of  lack  of  cleanliness)  consists 
in  proliferation  of  the  epidermis,  together  with  coriiification  and  the 
deposit  of  sejjum  between  the  layers  of  the  cells  and  in  the  excretory 
ducts  of  the  sebaceous  glands.  The  lesion  appears  in  the  form  of 
multiple,  dirty  yellow  or  brown,  circumscribed,  scaly  deposits  of  oily 
consistency  or,  at  times,  form  warty  excrescences.  Forcible  scrubbing 
of  the  skin  removes  the  deposit  and  usualh'  exposes  the  corium,  which 
bleeds  readily.  Repeated  removal  of  the  crusts  is  followed  by  the 
development  of  flat  ulcers  which,  when  protected  with  a  clean  ointment, 
soon  heal,  though  unduly  rough  manipulations  may  cause  the  ulcers  to 
persist.  The  process  is  differentiated  from  carcinoma  by  its  flatness, 
by  the  absence  of  hard,  sharply  defined  borders,  and  by  the  fact  that 
it  does  not  show  a  tendency  to  extend. 

In  addition  to  those  mentioned,  favorable  conditions  to  the  develop- 
ment of  carcinoma  are  presented  by  scar  tissue,  injuries,  chronic  skin 
iilcers  (syphilitic  or  tuberculous  ulcers  of  the  leg,  neuropathic  ulcer, 
burns  and  X-ray  ulcers)  and  persistent  fi^tulae.  Occasionally  carci- 
noma develops  in  the  scar  tissue  of  a  recent  wound.  In  these  cases  the 
single  injury  must  be  regarded  as  the  essential  or,  at  least,  the  exciting 
cause  of  the  new  grou'th.  The  influence  of  repeated  traumatic  irrita- 
tion is  illustrated  in  carcinoma,  which  develops  at  the  mucocutaneous 
border  of  the  lip  in  connection  with  shaving.  Carcinoma  develops  in 
a  fistula  when  the  latter  has  persisted  for  many  years,  as  happens 
in  cases  of  fistula  in  ano  or  a  sinus  maintained  by  an  old  empyema. 

Carcinoma  of  the  skin  appears  in  three  forms,  the  flat,  the  deep, 
and  the  papillary. 


1266 


TUMORS 


Flat  Carcinomata  of  the  Skin. — Superficial  or  flat  carcinomata  of 
the  skin  are  of  great  clinical  importance  because  they  constitute  almost 
a  tenth  part  of  all  cases  of  cancer  (Gurlt,^^  Heimann^^).  It  occurs,  in 
the  cornified  and  non-cornified  forms,  as  a  small,  firm,  reddish  nodule, 
which,  being-  painless,  does  not  at  first  attract  attention.  As  time  goes 
on,  the  nodule  enlarges,  the  epidermis  exfoliates,  and  the  surface  of 
the  mass  becomes  moist  or  bleeds  and  is  covered  with  a  crust  or  by 
horny  masses.  This, 
together  with  the  ob- 
servation that  each  re- 
moval of  the  crust  re- 
veals an  enlargement 
in  the  ulcer,  makes 
manifest  the  presence 
of  a  serious  condition. 

When  the  epider- 
mis is  preserved  for  a 
long  time,  which  often 
occurs  in  the  non- 
cornifying  form  of 
cancer,  a  plate-like  or 
fungiform,  elevated, 
sharply  defined  no- 
dule is  formed.  The 
nodule  frequently 
contains  minute  cijsts 
filled  with  a  clear 
fluid.  In  basal  cell  and 
skin  gland  carcino- 
mata these  cysts  con- 
sist of  dilated  glandu- 
lar cancer  cones. 

As  long  as  the  cancerous  infiltrate  does  not  extend  into  the  deeper 
tissues,  the  ulcer  is  not  indurated  and  may  be  moved  with  the  skin. 
Extension  into  the  underlying  tissues  may  not  occur  for  a  long  time 
(years)  and  is  attended  with  considerable  pain.  When  the  crust, 
which  consists  of  dried  secretions  and  cancer  cells,  is  removed,  the 
delicate  vascular  stroma  bleeds.  The  exposed  surface  is  red  and  does 
not  at  first  exhibit  deep  fissures. 

As  the  proliferation  creeps  into  the  neighboring  tissues,  a  dense, 


Fig.  613. — -Flat  Carcinoma  of  the  Skin. 


CARCINOMATA 


1267 


wall-like,  narrow  border  is  created,  and  this  is  surmounted  by  elevated, 
undermined  epidermis  and  is  rather  sharply  outlined  against  the  floor 
of  the  ulcer. 

In  situations  where  the  cancer  mass  progresses  more  rapidly  than 
the  destruction  of  the  skin,  disiiitegration  of  the  new  growth  causes  the 
borders  of  the  resultant  ulcer  to  take  on  a  jagged  or  serpiginous, 
phagedenic  and  often  undermined  appearance. 

If  the  narrow  layer  of  carcinoma  cells  in  the  center  of  the  ulcer 
completely  disintegrates,  proliferation  of  the  stroma  predominates  and 


Fig.  614. —  Advanced  Flat  Skin  Carcinoma,  Suitable  for  v.  Bruns'  Operation. 

causes  shrinkage  in  the  tumor  mass,  by  which  the  adjacent  healthy  skin 
is  thrown  into  radial  folds,  and  is  likely  to  be  attended  with  contrac- 
tural  deformation  of  the  eyelids  and  mouth.  At  times,  proliferation 
of  epidermis  extends  over  the  granulating  surface  of  the  ulcer  and 
epidermization  and  cicatrization  of  the  lesion  take  place.  In  this 
event,  the  underlj'ing  carcinomatous  proliferation  is  revealed  only  by 
a  slight  elevation  of  the  skin.  This  healing  is,  however,  only  apparent, 
and  the  cancer  proliferation  goes  on  beneath  —  a  condition  of  affairs 
conducive  to  a  dangerous  complacency. 


1268  TUMORS 

The  cicatrized  area  soon  breaks  down  under  the  influence  of  new 
confluent  ulceration,  which  extends  faster  than  before  and  clearly 
demonstrates  that  the  proliferation  of  cancer  cones  has  gone  busily  on 
beneath  the  mask  of  the  delusive  cicatrization  (Lexer^). 

V.  Bergmann-^  has  described  a  special  form  of  lupus-like  carcinoma 
of  the  temporal  region.  This  begins  in  the  form  of  small  nodules, 
which  disappear  without  ulcerating  and  are  followed  by  the  formation 
of  a  flat,  hairless  scar.  In  the  meantime,  additional  nodules  develop 
(in  the  outline  of  a  bow)  in  the  tissues  close  to  the  healed  process. 
The  lesion  may  attain  considerable  size.  Lexer^  reports  a  case  of  this 
sort  in  which  the  microscopical  examination  revealed  the  structure  of 
a  basal  cell  carcinoma. 

Superficial  carcinomata  of  the  skin  grow  very  slowly.  Many  years 
may  elapse  before  the  gradually  extending  ulcer  of  the  face  and  scalp 
(also  the  cheek,  eyelids,  nose,  temple,  forehead,  and  ear)  involves 
exte7isive  areas,  invades  the  deeper  structures  and  attacks  the  bone, 
which  it  often  converts  into  a  crumbling  mass,  and  gains  access  to  the 
cavities  of  the  face  and  through  them  exposes  the  dura. 

A  resume  of  the  behavior  of  flat  cancer  of  the  skin  may  be  stated  as 
follows:  It  consists  of  a  slowly  extending,  mostly  flat  ulcer 
vv^iTH  slightly  ELEVATED  BORDERS,  which  are  often  SERPIGINOUS  and 

UNDERMINED;  ITS  BASE  IS  SLIGHTLY  FISSURED,  IT  IS  COVERED  W^ITH  A 
CRUST,  BLEEDS  FREELY,  IS  SLIGHTLY  INDURATED,  SHOWS  A  TENDENCY  TO 
SHRINK,  TO  CICATRIZE  AND,  APPARENTLY,  TO  HEAL.      When  neglected,   it 

extends  into  the  deeper  tissues. 

The  neighboring  lymph  nodes  are  involved  late,  and  in  basal  cell 
carcinoma  are  only  involved  when  the  subcutaneous  tissues  are  invaded. 
Invasion  of  the  latter  is  heralded  by  their  induration  and  swelling. 

Hematogenous  metastases  are  rare. 

The  diagnosis  of  fiat  carcinoma  of  the  skin  is  based  on  its  peculiar- 
ities as  stated.  Gummatous  ulcers  have  a  sloughing,  necrotic  base  and 
sharply  defined,  undermined  borders,  though  it  must  be  admitted  that 
they  often  possess  flat,  phagedenic,  and,  at  times,  undermined  edges, 
and  a  clearly  defined  red  or  yellowish  base  covered  wdth  caseous  granu- 
lations. Both  of  these  are  rarely  single  and  are  usually  attended  with 
similar  disturbances  near  the  lesions  or  at  a  remotely  located  portion 
of  the  body,  while  the  multiple,  simultaneous  appearance  of  skin  cancer 
is  exceedingly  rare.  Flat  ulcers  emanating  from  adenomata  of  the 
skin  glands  or  from  seborrheic  changes  never  have  thickened  edges. 
Recognition  of  non-cornified  skin  cancer   (especially  of  the  face  and 


CARCINOMATA 


1269 


scalp)  is  possible  only  in  the  plate  and  fungiform  type,  to  which  the 
small  cysts  impart  a  certain  degree  of  transparency  and  softness. 
When  ulceration  has  occurred,  they  can  be  separated  from  cornified 
cancer  only  with  the  assistance  of  the  microscope. 

Complete  excision  of  the  lesion  is  the  only  treatment  which  achieves 


Fig.  615. —  Nodular  Carcinoma  which  Developed  upon  a  Varicose  Ulcer  of 

THE  Leg. 
The  fibula  has  been  partially  destroyed  by  the  growth. 

relief.  All  other  procedures,  cauterization  with  the  thermocautery  or 
with  caustic  acids  and  pastes,  exposure  to  the  X-ray  or  the  use  of 
radium,  do  not  accomplish  the  purpose  with  certainty  nor  permanency. 
Recurrence  follows  excision  in  only  a  small  proportion  of  the  cases 
(4.5  per  cent,  Borrmann^^).  On  the  other  hand,  the  emplo^yment  of 
so-called  bloodless  methods  is  frequently  followed  by  healing,  while 


1270  TUMORS 

the  process  extends  beneath  the  surface.  Korbl,^*  who  has  made  a 
careful  study  of  the  histological  changes  coincident  to  the  X-ray  treat- 
ment of  this  class  of  cases,  sounds  a  warning  in  this  connection  which 
would  seem  to  be  supported  by  clinical  observation. 

Excision  of  the  carcinomatous  ulcers  should  include  a  liberal  por- 
tion of  the  healthy  contiguous  tissues.  On  the  face,  the  extent  of  the 
incision  may  make  the  use  of  pedunculated  or  free  transplants  neces- 
sary to  close  the  defect.  On  the  forehead  and  on  the  other  surfaces  of 
the  body,  the  use  of  strips  of  epidermis  accomplishes  the  purpose. 
When  the  bone  is  invaded,  the  diseased  area  must  be  freely  excised 
with  the  chisel.  When  the  eyelids  are  involved,  the  eyeball,  together 
with  the  entire  contents  of  the  orbital  cavity,  must  be  removed. 

Diseased  or  suspicious  lymph  nodes,  together  with  the  surrounding 
connective  and  fatty  tissues,  must  be  extirpated.  At  times  these  organs 
are  involved  simply  in  a  reactive  inflammatory  process. 

Extensive  dissemination  of  the  process  renders  the  condition  inope- 
erahle.  In  these  cases,  the  local  use  of  zinc  chlorid,  of  the  cautery,  and 
of  antiseptic  solutions  is  justified,  on  the  ground  that  they  prevent 
putrefactive  infection  and  make  the  fate  of  the  host  more  bearable. 

Deep  Carcinomata  of  the  Skin. —  Deeply  extending  carcinomata 
of  the  skin  begin  in  the  form  of  small,  round  nodules  which,  as  is  indi- 
cated by  their  deep  seats,  originate  in  the  sebaceous  glands,  the  hair 
follicles,  and  perhaps  also  in  the  sweat  glands,  or  they  are  the  result  of 
extension  of  a  long,  persistent,  superficial  flat  carcinoma.  The  lesion 
evinces  the  characteristics  of  a  new  growth  far  more  clearly  than  ob- 
tains in  connection  with  flat  cancer.  Like  the  latter,  it  appears  more 
frequently  upon  the  face,  i.  e.,  the  nose,  the  eyelids,  the  vermilion 
border  of  the  lips,  in  which  the  picture  of  mucous  membrane  carcinoma 
is  also  present. 

As  deep  cutaneous  carcinoma  disintegrates  early  and  rapidly  infil- 
irates  the  surrounding  tissue,  it  causes  considerable  pain  and  is  soon 
attended  with  idceration.  The  ulcer  has  a  hard,  indefinitely  outlined 
hase  which  is  immovably  attached  to  the  underlying  tissues  (fascia, 
bone  —  for  instance  to  the  lower  jaw),  and  presents  deep  fissures  or 
crater-like  excavations,  which  at  times  are  covered  with  crusts  and  are 
readily  caused  to  bleed.  At  intervals,  characteristic  carcinoma  cones 
may  be  expressed  from  the  hottom  of  the  ulcer.  The  infiltrated  border 
of  the  ulcer  is  irregularly  excavated  and  forms  a  hard,  often  nodular, 
elevation  which  varies  in  height  and  thickness.  Its  conformation  may 
be  compared  to  a  wall,  the  superior  edge  of  which  overhangs  the  sur- 


CARCINOMATA  1271 

rounding  skin.  The  epidermis  ends  abruptly  at  the  foot  of  the  ele- 
vated tissue,  or  it  may  reach  to  its  summit.  A  lesion  of  this  sort 
secretes  a  bloody  fluid  which  often  emits  a  foul  odor.  Severe  hleeding 
indicates  erosion  into  a  large  artery. 

Extension  of  the  process  is  attended  with  the  formation  of  nodular 
or  papillary,  heavily  cornified  proliferation  into  the  base  of  the  ulcer, 
which  often  fills  it,  and  at  times  extends  beyond  the  level  of  the  con- 
tiguous skin  in  the  form  of  excrescences.  This  indicates  that  the  car- 
cinoma has  merged  into  the  papillary  form  of  skin  cancer. 

The  contiguous  lymph  nodes  are  involved  early  in  the  process.  They 
are  converted  into  large,  nodular  tumors  and  often  coalesce  with  the 
primary-  lesion  and  ulcerate  with  it,  so  that  destruction  of  extensive 
areas  occurs. 

Hematogenous  metastases  are  infrequent. 

The  malignant  and  rapidly  progressing  character  of  the  affliction 
renders  an  early  diagnosis  imperative.  The  rapid  development  and 
disintegration  of  a  round  nodule  followed  by  the  formation  of  an 
indurated  ulcer,  or  the  sudden  enlargement  and  ulceration  of  an  old 
wart  or  papilloma,  especially  w^hen  these  are  situated  in  an  area  of 
chronic  inflammation,  should  arouse  suspicion  of  the  presence  of  a 
malignant  process,  even  though  absolute  proof  of  carcinoma  is  not 
available. 

As  regards  treatment,  wtoe  excision  of  the  lesion  is  the  only 
PROCEDURE  WORTHY  OF  CONSIDERATION.  This  must  be  cxecutcd 
promptly  and,  when  the  growth  occurs  upon  the  face,  it  often  becomes 
necessary  to  resect  the  underlying  bone. 

The  care  of  lymph  node  metastases  and  inoperable  tumors  is  similar 
to  that  employed  in  connection  with  flat  carcinoma. 

Papillary  Carcinomata  of  the  Skin. —  Cutaneous  papillary  carci- 
nomata  are  characterized  by  the  early  elevation  of  the  growth  ahove 
the  surface  of  the  skin.  They  usually  develop  from  small  nodules, 
wart-like  growths,  or  carcinomatous  ulcers,  and  appear  as  pedunculated 
or  hroad  tumors  in  a  zone  of  hard  infiltration.  These  tumors  possess 
a  firm,  nodular,  cauliflower-like  or  papillomatous  surface  with  deep 
depressions,  and  are  often  covered  with  horny  7nasses  or  with  crusts 
which  consist  of  dried  secretions.  The  skin  is  clearly  defined  against 
the  base  of  the  growth.  The  sectioned  surface  reveals  long,  many 
branched,  papillary  formations  developing  from  the  carcinomatous 
masses  which,  early  in  the  process,  do  not  extend  into  the  surrounding 
tissues. 


1272 


TUMORS 


Skin  carcinomata  of  the  extremities  and  on  the  penis  (where  they 
also  arise  from  the  mucosa  of  the  glans  and  the  inner  layer  of  the 
prepuce)  form  similar  growths.  They  often  develop  from  benign 
fihro-epithelial  tumors  and  in  scars,  fistulae,  and  ulcers,  of  which 
ulcus  cruris  varicosum  (Fig.  615)  and  disintegrated  lupus  of  the  face, 


Fig.  616. —  Carcinoma  of  Penis. 


are  the  most  common.  Papillary  carcinomata  also  arise  in  connection 
with  atheromata,  and  dermoid  cysts,  in  which  event  they  break  through 
the  capsule  and  grow  out  as  from  a  cup. 

The  sudden  rapid  growth  of  a  previously  quiescent  warty  tumor 
should  arouse  suspicion  of  the  development  of  malignant  changes. 
The  appearance  of  a  small;  round,  hard  nodule  in  the  flabby  granula- 


CARCINOMATA  1273 

Ljiis  of  an  old  ulcer  is  the  first  warning  of  malignant  growth  and  is 
soon  followed  by  elevation  and  induration  of  the  border  of  the  ulcer. 

The  contiguous  lymph  nodes  are  invaded  early.  General  metastatic 
formations  follow  in  a  certain  number  of  cases. 

Early  radical  extirpation  of  the  process  may  obviate  recurrence. 
When  the  fascia  of  a  limb  is  invaded,  imputation  is  justified.  It  is 
not  wise  to  err  on  the  side  of  timidit}^  in  this  connection.  In  carci- 
noma of  the  penis,  amputation  is  always  indicated. 

In  other  respects  the  treatment  of  papillary  carcinoma  is  similar  to 
that  of  the  other  forms. 

Carcinomata  of  Mucous  Membranes. —  Carcinomatous  invasion  of 
mucous  membranes  takes  on  a  variety  of  forms.  They  may  be  papil- 
loid,  hroadhj  attached  or  pediculate,  nodular,  spongy,  cauliflower-like, 
or  papillomatous,  lohulated  tumors.  At  times,  the  growth  is  flat;  at 
others,  deeply  ulcerated;  and,  in  not  a  few  instances,  diffusely 
infiltrating. 

They  also  A^ary  in  structure  (this  is  determined  by  the  situation  in 
which  they  originate),  being  composed  of  either  flat  or  cylindrical 
epithelial  cells ;  or  the  tumorous  proliferation  maj^  begin  in  the 
glandular  elements  contained  within  the  affected  zone  of  mucosa. 

Flat  epithelial  cancers  with  cornification  (rarely  basal  cell  carci- 
nomata) are  most  often  found  on  the  tongue  and  the  lips,  of  which  the 
lower  lip  is  the  more  frequently  involved ;  they  also  develop  in  the 
oral  cavity  (the  cheek,  the  floor  of  the  mouth,  the  soft  palate,  the 
tonsil),  in  the  mamillary  sinus,  in  the  larynx,  in  the  esophagus,  at  the 
cardiac  end  of  the  stomach,  in  the  vagina,  in  the  cervix  uteri,  in  the 
mucosa  of  the  labia,  the  prepuce,  and  the  glans.  The  process  also 
originates  from  the  so-called  transitional  epithelium  of  the  mucous 
membranes  of  the  urinary  tract  and  in  this  situation  may  appear  in  the 
cornified  form.  When  the  cjdindrical  epithelial  form  of  the  process 
(gallbladder,  stomach,  trachea)  appears,  its  origin  would  seem  ascrib- 
able  to  displaced  embryonic  flat  epithelium  or  to  the  conveyance  of 
the  latter  to  the  tumor  site  in  connection  with  an  inflammatory  process 
(Borst^. 

The  changes  occurring  in  mucous  membranes  present  conditions 
favorable  to  the  development  of  proliferative  processes.  Cancer  arises 
from  fihro-epithelial  formations,  from  ulcers  of  all  kinds  (especially 
tuberculous,  and  perhaps  syphilitic),  and  from  scars  and  wounds.  In 
the  oral  cavity,  on  the  edge  of  the  tongue,  and  on  the  inner  aspect 


1274 


TUMORS 


of  the  cheek  continued  irritation   of   sharp   carious  teeth  plays   as 
important  a  part  as  leukoplakia  or  psoriasis. 

Leukoplakia  is  characterized  by  the  painless  appearance  of  whitish, 
light  gray  or  opalescent,  somewhat  elevated,  plaques  on  the  dorsum  of 
the  tongue,  more  often  than  on  its  edges ;   on  the  mucosa  of  the  cheek, 


Fig.  617. —  Carcinoma  and  Papilloma  of  Tongue. 
The  carcinoma  has  ulcerated. 

especially  at  the  corners  of  the  mouth;  on  the  lips;  and,  occasionally, 
on  the  soft  palate.  The  plaques  are  irregular  in  outline,  varying  in 
size,  and  firmly  attached  at  their  bases ;  they  are  formed  by  excessive 
proliferation  of  cornificd  epithelium. '  As  these  miniature  new  growths 
are  found  to  project  conelike  processes  into  the  submucosa,  it  would 
seem  that  the  development  of  carcinoma  may  be  ascribed  to  their 
presence. 


CARCINOMATA  1275 

The  lesions  appear  in  middle  life  and  may  be  harmless  for  many 
years  (thirty),  until  suddenly  a  hard,  painful  nodule  develops  in  the 
mucosa  beneath  one  of  the  epithelial  plaques.  This  may  occur  in  con- 
nection with  a  transient  inflammatory  process  in  the  zone  of  the  old 
lesion,  which  becomes  fissured  and  rough ;  or,  which  is  less  frequent, 
the  character  of  the  process  assumes  a  nodular  infiltrating  form  with- 
out any  apparent  cause.  In  some  cases,  carcinoma  begins  in  various 
sections  of  the  tongue  at  intervals  of  several  years.  The  simultaneous 
development  of  papilloma  at  one  portion  of  the  tongue  and  carcinoma 
at  another  is  shown  in  Fig.  617. 

As  leukoplakia  develops  almost  entirely  in  men,  and  usually'  in  heavy 
smokers,  it  is  assumed  that  the  causative  influence  of  tobacco  in  carci- 
noma is  similar  to  that  of  tar  and  paraffin  products  in  relation  to  skin 
cancer  (v.  Bergmann-^). 

The  treatment  of  leukoplakia  includes  abstinence  from  the  use  of 
tobacco.  Mild  non-irritating  mouth  washes  may  be  used.  When  the 
epithelial  plaques  are  fissured  and  surrounded  by  a  zone  of  inflamma- 
tion, they  should  be  destroyed  with  the  thermocautery. 

Progressively  increasing  hard  nodules,  which  are  so  indicative  of 
beginning  carcinoma,  should  be  excised,  using  elliptical  or  spindle 
shaped  incisions  for  the  purpose. 

Leukoplakia  occurs  also  on  the  male  and  female  genitals  and  is  to  be 
regarded  as  the  forerunner  of  earcinoma  in  this  situatit)n.  It  occurs 
more  often  on  the  mucosa  of  the  vagina  and  portio  than  on  the  glans  or 
prepuce  (Iwasaki^^). 

Squamous  cell  carcinomata  appear  upon  the  mucosa  in  the  same 
form  as  upon  the  skin.  Deeply  extending  carcinomata  with  crater- 
like, deeply  fissured  ulcers,  elevated  (often  nodular)  and  thickened 
borders,  and  far  reaching  indurated  bases,  frequently'  appear  upon  the 
tongue  and  lower  lip.  Papillary  carcinomata  coexist  with  flat  and 
deep  ulcers  in  the  mucosa  of  the  gut,  the  cheeks,  the  jaws,  the  pharynx 
and  the  larynx;  in  the  urinary  bladder;  in  the  pelvis  of  the  kidney; 
and  very  frequently  on  the  prepuce  and  glans  (Fig.  616),  where  they 
are  often  strongly  cornified. 

Growths  of  this  sort  begin  in  the  form  of  a  nodular  infiltrate,  which 
is,  at  first,  covered  by  mucous  membrane  and  merges  with  the  surround- 
ing tissues ;  after  a  brief  period  of  time  this  breaks  down  and  rapidly 
extends.  The  process  is  attended  with  severe  pain,  especially  when 
the  lesion  is  located  in  the  area  of  distribution  of  the  fifth  nerve. 


1276 


TUMORS 


Squamous  cell  carcinomata  of  the  mucosa  bleed  much  more  readily 
than  those  of  the  skm  and  are  very  likely  to  undergo  putrefactive  dis- 
integration. In  carcinoma  of  the  mucosa  of  the  bladder  or  pelvis  of 
the  kidney,  bleeding  is  an  early  symptom.  Disintegration  of  the  tumor 
mass  is  attended  with  the  discharge  of  a  foul  secretion  which,  when 
swallowed,  causes  serious  digestive  disturbances,  and,  when  aspirated 
into  the  lung,  gives  rise  to  lobular  pneumonitis. 

Shrinkage  of  the  tumor  mass  causes  menacmg  stenoses  of  the  larynx 
and  esophagus.  Sudden  edematous  swelling  of  the  mucosa  gives  rise 
to  dyspnea  and  obstruction  to  deglutition. 

Mucous  membranes  covered  with  cylindrical  epithelium,  and  their 
glandular    content,    give 
origin  to  carcinomata  which 
present    many    structural 
transitions. 

Those  developing  from 
the  former  present  gland- 
like, tubular  cancer  cones 
which  are  covered  with  a 
single  row  or  several  strati- 
fied layers  of  cylindrical 
epithelium  that  communi- 
cate with  one  another.  The 
variations  in  conformation 
of  the  cellular  columns  and 
the  arrangement  of  their 
lumina  give  to  the  micro- 
scopic section  an  exceed- 
ingly varying  picture.  A  certain  number  of  the  epithelial  cells  are 
goblet  shaped  and  secrete  mucus.  Usually  they  are  not  regularly 
arranged,  as  in  the  glands,  but  are  often  gathered  together  in  club 
shaped  masses  which  join  to  meet  similar  groups  of  cells  arising  from 
the  opposite  walls  of  a  tubule. 

Portions  of  gland  epithelial  carcino'mata  are  also  tubidar  in  struc- 
ture; the  rest  of  the  tumor  is  composed  of  solid  cones,  so  that  histolog- 
ically gland  carcinomata  are  divided  into  adenomatous  and  solid 
varieties. 

A  special  form  of  this  class  of  tumor  —  colloid  mucoid  carcinoma  — 
owes  its  distinctive  classification  to  an  over  secretion  of  mucus.  This 
growth  is  composed  of  cells  which  are  distended  with  mucous  plugs 


Fig.  CIS.- 


XoDULAR  Carcinoma  of  the 
Maxilla. 


Healed  by  total  resection. 


CARCINOMATA 


1277 


and,  because  of  the  lateral  position  of  their  nuclei,  are  called  "seal  ring 
cells"  (Ribbert^).  The  mucous  secretion  either  fills  the  lumina  of  the 
cones  or  dislodges  the  cells  from  the  thin,  often  degenerated  (mucoid) 
columns  of  stroma.  At  times,  round  or  conical,  cylindrical  mucous 
corpuscles,  surrounded  hy  cells,  lie  within  the  solid  cancer  columns,  so 
that,  on  transverse  section,  numerous,  small,  round,  open  spaces,  not 
unlike  those  found  in  cylindroma  (carcinoma  cylindromatosum), 
appear  in  the  microscopical  picture. 

MacroscopicaUij,  colloid  carcinoma  consists  of  a  vitreous,  translucent, 
soft  mass  from  which,  on  a  section,  a  sticky  substance  oozes. 


Fig.  619. —  Colloid  Carcixoma  of  Stomach. 

Cylindrical  cell  and  adenocarcinomata  of  mucous  membranes  appear 
mostly  in  the  gastro-intestinal  canal,  especially'  at  the  pylorus  and  the 
lesser  curvature  of  the  stomach,  at  the  cecum  (Fig.  621),  at  both  flex- 
ures of  the  colon,  and  in  the  rectum.  In  addition  to  this,  they  develop 
in  the  mucosa  of  the  nose,  the  larynx,  the  gallbladder,  the  cervix  and 
the  body  of  the  uterus.  Occasionally,  a  growth  of  this  sort  originates 
at  the  branchial  clefts  of  the  neck  {branchiogenic  carcinoma)  from 
displaced  epithelial  rests,  or  from  the  tissues  of  a  teratoid  mixed  tumor. 
A  not  inconsiderable  number  arise  from  tdcers  and  fibro-epithelial 
tumors  (multiple  intestinal  polypi)  of  the  stomach  and  the  gut. 


1278 


TUMORS 


Like  flat  cell  carcinoma,  cylindrical  cell  carcinoma  begins  beneath 
the  mucosa,  at  first  as  a  hard,  circumscribed,  apparently  benign, 
nodule,  which,  however,  is  soon  converted  into  a  flat  or  deep  ulcer.  In 
the  gut  and  at  the  pylorus  these  ulcers  extend  around  the  lumen  and 
are  surrounded  by  elevated  hard  borders.  When  the  process  remains 
dominantly  nodular, 
cauliflower-like  or  papil- 
lomatous in  character, 
the  lumen  of  the  affected 
viscus  becomes  imper- 
meable; this  also  hap- 
pens when  shrinkage 
attends  the  ulcerative 
form  of  the  process. 
Putrefactive  disintegra- 
tion and  hemorrhage 
occur  early  in  gastro- 
intestinal lesions  because 
of  the  constant  irritation 
caused  by  the  contents, 
and  are  evinced  by  the 
appearance  of  blood  and 
broken  down  particles 
of  tissue  and  mucus  in 
the  vomit  or  in  the 
stool. 

Many  forms  of  the 
process  rapidly  and 
widely  infiltrate  the 
walls  of  the  stomach  and 
gut  and,  without  ulcer- 
ating, convert  extensive 
areas  into  rigid,  tubular 
formations,  the  thick-  I'ig. 
ened,  nodular,  inner  sur- 
face of  which  is  covered 
with  immovable  mucosa,  while  the  outer  is  studded  with  small  lymph 
nodes. 

Perforation  of  the  wall  of  the  stomach  and  gut  is  followed  by  putre- 
factive peritonitis.  When  the  growth  extends  simply  to  the  perito- 
neum, the  proliferation  invades  contiguous  organs  and  may  establish 
communication  between  them  by  ulcerative  destruction. 


Duodenum   at 


620. —  Adenocarcinoma    of 
Site  of  Papilla. 

(Symmers,  Bellevue  Hospital  case.) 


CARCIXOMATA 


1279 


Colloid  carcinomata  occur  most  frequenth'  in  the  rectum,  though 
the}-  also  develop  in  the  stomach  and  in  the  ce^um.  They  extend  over 
wide  areas  and  have  a  tendency  to  infiltrate  the  wall  of  the  gut,  the 
mesentery,  the  omentum,  the  appendices  epiploicae  and  to  disseminate 
throughout  the  entire  peritoneum. 

Early  recognition  of  carcinomata  of  mucous  membrane  (which  is 
so  important  in  its  treatment)  is  beset  with  great  difficulties.  This  is 
due  to  the  concealed  position  the  growths  often  occupy,  to  the  fact  that 
they  do  not  give  rise  to  symptoms  until  the  disease  is  far  advanced,  and 
is  also  because  their  clinical  course  frequently  resembles  that  of  less 
menacing  conditions. 

In  the  oral  cavity  they  may  be  recognized  promptly.     Here,  chiefly 


Fig.  621.— Nodular,  Circular  Carcixoma  of  the  Cecum,  the  Cexter  or  which 

Ulcerated. 

The  carcinoma  was  situated  close  to  the  ileocecal  valve. 


because  of  their  frequent  association  with  leukoplakia,  the}''  may  be 
mistaken  for  lues.  When  a  section -of  doubtful  tissue  is  excised  for 
microscopical  examination,  care  should  be  taken  to  remove  a  goodly 
sized  portion  of  the  growth,  together  with  a  sector  of  normal  tissue. 

In  other  portions  of  the  body,  the  symptoms  depend  upon  the  seat 
of  the  lesion.  In  the  larnyx,  hoarseness  is  an  early  sjinptom:  in  the 
stomach  and  gut,  vomiting,  chronic  catarrh,  and  the  picture  of  ileus 
are  produced.  Blood  in  the  stools  occurs  in  carcinoma  of  the  rectum. 
Blood  in  the  urine  should  arouse  suspicion  in  connection  with  the 
nrinarj/  bladder  and  hidney.  However,  all  of  these  s}Tnptoms  also 
occur  in  less  harmful  conditions. 

In  situations  where  the  tumor  is  visiile  and  palpable,  the  character- 


1280  TUMORS 

istics  of  the  ulcer  or  of  the  proliferation,  the  hardness  of  its  borders, 
its  surface  and  its  base  and,  in  advanced  cases,  the  presence  of  an  ex- 
tensive infiltrate  with  adhesions  of  contiguous  parts,  and  the  enlarge- 
ment of  the  lymph  nodes  are  factors  of  diagnostic  value.  In  suspected 
cancer  of  the  gastrointestinal  canal,  the  employment  of  exploratory 
laparotomy  is  justified.  When  the  tumor  is  palpable  through  the  ab- 
dominal well,  the  diagnosis  is  clear,  but  the  probabilities  of  affording 
relief  are  not  great. 

The  treatment  consists  in  early  and  complete  removal  of  the  lesion. 

Carcinoma  of  Glandular  Organs. —  The  structure  of  gland  carcinoma 
varies  with  its  origin,  as  carcinoma  of  the  mamma,  the  pancreas,  the 
kidney,  the  liver,  ovaries  and  scrotum,  the  thyroid  gland,  the  prostate, 
the  parotid  and  glands  of  the  skin  and  mucosa. 

In  a  general  M'ay,  cancers  originating  from  gland  epithelium  are 
divided  into  adenomata  and  solid,  i.  e.,  those  composed  of  gland-like 
tissue  and  those  composed  of  solid  cancer  cones  or  processes.  The 
epithelial  cells  concerned  in  proliferation  are  cylindrical,  ciibical  or 
polymorphous,  and  are  found  in  single  layers  or  are  stratified,  thus 
presenting  great  irregularity  of  arrangement.  The  secretions  fur- 
nished by  the  cells  vary  in  accord  with  their  character,  so  that  the 
cylindrical  cells  of  the  thyroid  gland  furnish  colloid,  those  of  the  liver, 
bile,  while  others,  for  instance  those  of  the  mamma,  like  the  glandular 
epithelial  cells  of  carcinoma  of  the  gastro-intestinal  tract,  furnish 
mucus. 

When  the  secretion  is  excessive,  it  distends  the  gfandular  tubules, 
which  coalesce  or  open  into  disintegrated  sectors  of  the  tumor,  so  that 
large  and  small  hollow  spaces  are  formed.  Often,  papillae  proliferate 
from  the  walls  of  these  hollow  spaces  or  cysts  and  may  entirely  fill 
them,  thus  forming  the  cystocarcinoma  papilliferum  so  often  found  in 
the  mamma  and  the  ovary. 

Mucoid  degeneration  leads  to  the  formation  of  a  colloid  carcinoma, 
as  it  does  in  cylindrical  cell  cancer.    • 

From  a  clinical  standpoint,  as  obserA-ed  in  connection  with  the 
female  breast,  chronic  inflammatory  processes,  hlunt  trauma,  and  the 
presence  of  henign  tumors,  such  as  cystadenoma,  would  seem  to  pre- 
dispose to  the  development  of  carcinoma. 

The  clinical  manifestations  of  carcinomata  of  organs  do  not  vary 
widely,  except  for  a  considerable  difference  in  consistency,  being  hard 
(scirrhous)  or  soft  {medullary  form).  They  begin  as  round,  not  very 
clearly  defined,  tumors,  which  successivel}^  invade  the  surro^mding 


CARCINOMATA 


1281 


tissues  and  destroy  and  replace  them.  When  the  surface  of  the  organ 
in  which  they  originate  is  reached,  the  process  extends  to  a  neighbor- 
ing organ;  e.  g.,  when  the  prostate  or  uterus  is  primarily  involved, 
the  destructive  proliferation  goes  on  into  the  bladder  and  the  rectum. 
When  the  skin  or  mucosa  is  reached  and  perforated,  the  process  forms 
deep  ulcers  and  nodular  protuberances. 

Lexer^  presents  a  description  of  the  clinical  course  of  this  form  of 
carcinoma  as  follows : 

' '  The  best  example  of  a  gland  cancer  in  an  organ  is  presented  by  the 
female  breast.  A  nodule,  which  has  not  given  rise  to  symptoms,  is  acci- 
dentally discovered.    It  represents  a  mass  about  the  size  of  a  cherry,  is 

hard,  lies  within  the 
breast,  has  indefinite  bor- 
ders, and  is  manifestly 
adherent  to  its  environ- 
ment. The  superimposed 
skin  is  not  as  freely  mov- 
able as  that  covering  the 
rest  of  the  gland.  When 
the  tumor  is  located  be- 
neath, or  in  the  region  of, 
the  nipple,  the  latter  is 
somewhat  retracted  and 
cannot  be  delivered  from 
its  surrounding  alveolus 
because  of  the  action  of 
the  shortened  projections 
of  the  new  growth.  The 
hardened  area  gradually 
increases  in  size;  drawing  pain  develops;  and  a  hard,  nodular, 
dark  red  infiltrate  discolors  the  skin  over  the  tumor  and  is  con- 
tinuous with  it,  while  the  growth  becomes  adherent  to  the  fascia 
of  the  pectoralis  major  and  the  wall  of  the  thorax,  so  that  the 
tumor  can  no  longer  be  moved  on  the  muscle  and  ribs  with  the  breast 
(medullary  form),  or  shrinks  and  forms  a  nodular  infiltrate,  which  is 
adherent  to  the  thoracic  wall  and  presents  a  more  or  less  ulcerated 
surface  (scirrhous).  Lymph  node  metastases  appear  in  the  axilla, 
either  early  or  late  in  the  process.  Bleeding  from  the  ulcerated  area 
may  be  menacing  and  originates  from  the  intercostal  or  the  internal 
mammary  arteries.    Hematogenous  metastases  develop  in  the  lung,  in 


Fig.  622.- 


SciRRHOus  Carcinoma  of  the 
Breast. 


1282  TUMORS 

the  liver,  aaid  in  other  organs  and,  not  infrequently,  in  the  bones. 
Death  follows  as  the  result  of  increasing  cachexia  and  from  hemor- 
rhage. ' ' 

The  clinical  manifestations  of  carcinomata  of  organs  depend  upon  the 
seat  of  the  lesion. 

The  Clinical  Course  of  Carcinoma. —  The  various  carcinomata  are  all 
characterized  by  progressive  local  extension  and  destruction,  by  the 
formation  of  lymphogenous  and  hematogenous  metastases,  and,  j&nally, 
by  the  development  of  cancer  cachexia.  However,  the  collective  pic- 
ture varies,  being  slow  or  rapid  in  its  course,  depending  upon  the 
seat  of  the  tumor  and  the  secondary  metastatic  formations  by  which 
it  is  followed.  The  cause  of  death  is  not  always  the  same ;  it  is  influ- 
enced by  the  location  of  the  process.  In  a  certain  number  of  cases, 
death  is  hastened  by  perforation,  peritonitis,  meningitis,  or  aspiration 
pneumonitis ;  while  in  others,  the  fatal  outcome  is  due  to  progressive 
general  exhaustion. 

Sooner  or  later,  the  general  condition  of  every  person  afflicted  with 
cancer  undergoes  grave  changes,  and  emaciation,  feebleness,  and  anemia 
unite  with  the  cancer  cachexia.  The  latter  is  ascribed  in  part  to  the  ab- 
sorption of  the  products  of  disintegration  of  the  tumor  mass,  and  in 
part  to  secondary  disturbances  (frequent  bleeding,  interference  with 
nourishment,  etc.),  and  to  metastatic  involvement  of  important  vital 
organs. 

The  prognosis  is  had,  but  not  always  to  the  same  degree.  Flat  skin 
carcinomata  are  comparativehj  &gmf/w,  as  they  grow  and  destroy  slowly 
and  form  metastases  late.  The  worst  form,  is  the  rapidly  infiltrating, 
soft,  colloid  carcinoma  of  organs  and  mucous  membranes.  The  carci- 
nomata of  youth  and  middle  life  are  usually  more  malignant  than 
those  occurring  late  in  life.  In  a  general  way  they  terminate  the 
picture  in  from  two  to  three  years.  The  flat  skin  cancers  are  not 
nearly  so  quickly  fatal. 

Permanent  relief  is  only  possible  when  the  lesion  is  promptly  and 
thoroughly  extirpated.  The  available  statistics  vary  widely  and  are 
much  influenced  by  the  location  and  character  of  the  process,  by  the 
extent  of  the  operative  procedure  necessary  to  radical  extirpation  of 
the  growth,  and  to  a  considerable  extent  by  the  technical  qualifications 
of  the  surgeon.  It  is  also  gratifying  to  be  able  to  record  that  the 
number  of  cases  of  permanent  relief  following  operative  efforts  is  con- 
stantly increasing  as  early  diagnoses  are  made  and  the  operative 
technic  improves. 


CARCINOMATA  1283 

The  operative  treatment  of  cancer  affords  relief  only  in  those  cases 
in  which  complete  extirpation  of  the  lesion  is  feasible  without  endan- 
gering  the  life  of  the  host.  The  conclusion  in  this  connection  is  based 
on  the  extent  of  the  primary  tumor,  the  de^ee  of  lymph  node  involve- 
ment, and  the  presence  of  hematogenous  metastases.  The  latter  make 
operative  efforts  at  relief  a  useless  measure.  As  regards  lymph  node 
metastases,  clinical  experience  must  be  taken  into  account.  For  in- 
stance, when  there  is  only  a  small  tumor  in  the  breast  and  both  the 
axillar}'  and  supraclavicular  nodes  are  involved,  the  case  is  inoperable. 

Recurrence  after  operation  occurs  more  frequently  in  the 
area  from  which  the  lymph  nodes  have  been  removed  than  at 
THE  SITE  OF  THE  EXCISED  PRIMARY  TUMOR.  This  is  explained  on  the 
ground  that,  despite  the  removal  of  visibly  invaded  lymph  nodes,  to- 
gether with  their  surrounding  fatt\'  and  connective  tissue,  unobserved 
carcinomatous  lymph  nodes  may  be  left  in  situ.  Local  recurrence  is 
most  likely  to  develop  in  situations  where  the  primary  seat  of  the 
tumor  lies  close  to  tissue  rich  in  lymphatics.  Recurrences  which  de- 
velop in  the  neighborhood  of  the  scar  a  long  time  after  the  operation 
may  be  regarded  as  new  grovxths  when  the  conditions  in  the  tissues 
contiguous  to  the  site  of  the  original  tumor  favor  the  development  of 
carcinoma  (such  as  leukoplakia). 

The  treatment  of  inoperable  carcinoma  is  taken  up  on  page  1116. 

Wliether  so-called  implantation  recurrences,  arising  as  the  result  of 
implantation  in  the  wound  of  particles  of  the  tumor,  occur  or  not  is  not 
easily  determined.  The  possibility  of  the  lymphog^^enons  transmission 
of  cancer  particles  would  have  to  be  excluded. 

The  question  of  the  causation  of  carcinoma  is  unsolved.  The  more 
important  points  in  this  connection  have  been  taken  up  in  another 
portion  of  this  book  (p.  1091). 

The  fact  that  carcinomatous  proliferation  often  occurs  in  areas  of 
changed  tissues,  in  wounds  and  scars,  in  ulcers  of  all  kinds,  in  benign 
tumors,  and  in  zones  of  chronic  inflammation  is  regarded  by  the  fol- 
lowers of  Virchow's-®  irritation  theory  as  showing  that  the  process  is 
dependent  upon  changes  in  the  character  of  the  cells  (cell  chemicus, 
BlumenthaP")  which  provoke  them  into  atypical  proliferation.  The 
congenital  occurrence  of  carcinomata  and  the  demonstrable  presence 
of  embryonic  rests  in  certain  tumors  of  this  class  would  seem  to  sup- 
port the  theory  of  Cohnheim,^*  that  the  new  growth  originates  from 
embryonic  tissue.  According  to  Ribbert,*  the  basic  cause  of  carci- 
noma lies  in  the  separation  of  small  groups  of  epithelial  cells  from, 


1284         '  TUMORS 

their  normal  environment,  following  proliferation  of  connective  tissue, 
which  may  be  caused  by  a  number  of  destructive  influences. 

The  parasitic  theory  still  has  its  following,  chiefly  because  cancer 
so  often  develops  in  areas  which  are  subjected  to  all  kinds  of  irrita- 
tion, and  in  locations  (orifices  of  the  body,  and  certain  sectors  of  the 
gastro-intestinal  canal)  where  chronic  inflammatory  processes  or  ulcers 
of  various  kinds  are  commonly  found ;  also,  because  of  the  development 
of  the  lesion  in  husband  and  wife  and  in  several  memhers  of  the  same 
family,  conditions  which,  from  a  clinical  standpoint,  tend  to  indicate 
infection.  However,  as  yet,  the  microorganism  of  cancer  has  not  been 
discovered. 

It  is  fair  to  state  that  cancer  is  not  contagious,  although  Blumen- 
thal's^^  work  upon  animals  presents  a  possibility  in  this  connection. 

To  the  clinician,  cancer  would  seem  to  be  hereditary.  It  is  not 
impossible  that  the  tendency  to  cancer  development  is  inherited. 

BIBLIOGRAPHY 

1.  BoRST.     Die  Lehre  d.  Greschwiilste,  Wiesbaden,  1902. 

2.  MacCallum.     Textbook  of  Path.,  Phila.,  1916. 

3.  Lexer.    Allg.  Chir.  ii,  Stuttgiart,  1914. 

4.  Hauser.     Zylinderepith.  Karz.,  etc.,  Jena,  1890. 

5.  Koster.     Quoted  by  Ribbert  —  Geseliwiilstlehre,  Bonn,  1904. 

6.  Ribbert.     Die  Entstehung  des  Karzinoms,  Bonn,  1906 ;  also  Die  Entste- 

hung  d.  Geschwiilste,  Bonn,  1906  and  1908. 

7.  Petersen.     Beitr.  z.  Klin.  Chir.  Bd.  32,  1902,  mit  lit.,  also  Bd.  34,  1902. 

8.  Borst.     Beitr.  z.  path.  Anat.  Bd.  49,  1910. 

9.  Albrecht.     See  Borst  No.  1. 

10.  Beneke.     See  Borst  No.  1. 

11.  Fischer.    Miinch.  med.  Woch.,  1901. 

12.  Wacker.     Miinch.  med.  Woch.,  1910. 

13.  ScHMiNCKE.     Miinch.  med.  Woch.,  1911. 

14.  v.  Hansemann.     Zeitschr.  f.  Krebsforsch.,  Bd.  12,  1913,  H.  2. 

15.  v.  Lamezan.     Same  as  No.  14. 

16.  Abderhalden.     See  Apolant  No.  17. 

17.  Apolant.     In  Kolle-Wassermann's  Handb.  d.  jmth.  Mikroorg.  2  Aufl. 

Bd.  3,  1913,  with  lit. 

18.  Kromprecher.     Der  Basalzellenkrebs,  Jena,  1903,  with  lit. 

19.  BoRRMANN.     Zeitschr.  f.  Krebsforsch,  Bd.  2,  1904. 

20.  Kaposi.     See  Kromprecher  No.  18. 

21.  GuRLT.     Quoted  by  Bockenheimer,  Clinical  Surgery,  i,  Eebraan,  N.  Y. 

22.  Heimann.     Quoted  by  Bochenheimer,  Clinical  Surgery,  i,  Rebman,  N.  Y. 

23.  V.  Bergmann.     Handb.  d.  prakt.  Chir.,  Ed.  3,  i. 

24.  Korbl.    Arch.  f.  klin.  Chir.,  xcvii,  1912. 

25.  Iwasaki.     Deutsch.  Zeitschr.  f.  Chir.  cxix,  1912. 

26.  ViRCHOW.    Die  krank.  Geschwiilste,  Berlin,  1863. 

27.  Blumenthal.     Berlin,  klin.  Woch.,  1913,  No.  50. 

28.  Cohnheim.     Vorlesung  u.  AUgem.  Path.,  Berlin,  1882. 


CHAPTER  XVIII 
MALIGNANT  CHORIONIC  EPITHELIOMA 

Under  the  term,  chorionic  epithelioma  maligna,  Marchand^  described 
a  new  growth  which  develops  in  connection  with  pregnancy  (with 
abortion)  and,  in  one  half  the  cases,  in  consort  with  a  hydatid  mole 
in  the  ■uterus,  at  times,  in  the  vagina,  and,  after  tubal  pregnancy,  in 
the  tube.  It  originates  from  the  epithelial  cells  of  the  chorionic  villi 
(v.  Franque-).  The  other  terms,  such  as  deciduoma  maligna,  deciduo 
sarcoma,  are  based  on  the  assumption  that  the  process  originates  from 
the  connective  tissue  cells  of  the  decidua  (Sanger,^  Veit*). 

The  tumor  masses  consist  of  exceedingly  vascular  lobules,  which,  on 
section,  resemble  placental  tissue,  fill  the  entire  cavity  of  the  uterus, 
and  infiltrate  and  destroy  its  walls.  Severe  bleeding,  gangrenous  dis- 
integratian  of  the  affected  parts,  and  the  rapid  formation  of  hemato- 
genous metastases  attend  the  clinical  picture,  which  usually  ends 
with  a  fatal  outcome  in  a  few  months.  Progressive,  severe  anemia 
follows  the  uncontrollable  bleeding,  despite  repeated  emptying  of  the 
uterus,  which  is  usually  executed  in  the  belief  that  the  condition  is  one 
of  retained  placental  tissue.  The  putrid  disintegration  of  the  vagina 
affords  ready  ingress  to  infection,  which  often  becomes  general.  The 
tumor  masses  enter  the  blood  through  the  dilated  vessels  of  the  uterus 
and  soon  give  rise  to  metastases  in  the  lungs,  the  vagina,  and  later  in 
all  the  other  organs. 

The  double  epithelial  covering  of  the  chorionic  villosities  (originat- 
ing from  the  fetal  ectoderm),  together  with  mucoid  degeneration  and 
liquefaction  of  the  stroma  of  the  villi,  which  are  responsible  for  the 
cystic  mole,  is  regarded  by  Marchand^  as  the  mother  base  and  struc- 
ture material  from  which  chorionic  epitheliomata  also  arise.  The 
latter  are  composed  of  the  layer  of  cubical  cells,  described  by  Lang- 
hans,^  which  cover  the  connective  tissue  stroma  of  the  villi,  and  of  the 
poljTiuclear  layer  of  the  syncytium,  which  lies  above  these  but  is  not 
yet  divided  into  protoplasmic  cells.  In  the  typical  tumors,  the  ar- 
rangement of  the  epithelial  proliferation  is  similar  to  that  of  chorionic 

1285 


1286 


TUMORS 


epithelium;  in  the  atypical,  this  is  lost  and  the  elements  of  the  two 
layers  are  mixed  with  one  another  so  that  the  picture  is  not  unlike 
that  of  a  giant  cell  sarcoma.  The  rare,  primary  chorionic  epitheli- 
omata  of  the  vagina  are  probably  due  to  retrograde  wandering-  of  the 


Fig.   623. —  Chorionic   Epithelioma,   Showing 
Langhans'  Cells  and  Syncytium. 

already  pathological  chorionic  epithelial  cells  conveyed  by  way  of  the 
veins  of  the  uterus. 

Cell  proliferation,  similar  to  that  of  chorionic  epithelioma,  occurs 
occasionally  in  connection  with  teratoid  mixed  tumors,  and  also  in  the 
testicle  or  bladder  of  the  male  (Churin,®  Venuler,'  Dillmann,^  Stern- 
berg^). 


BIBLIOGRAPHY 

1.  Marchand.     See  v.  Franque  No.  2. 

2.  V.  Franque.     Zeitschr.  f.  Geburtshilfe.  u.  Gyn.  xHx,  1903,  with  lit. 

3.  Sanger.    See  v.  Franque  No.  2. 

4.  Veit.     See  v.  Franque  No.  2. 

5.  Langhans.     See  v.  Franque  No.  2. 

6.  Churin.     Med.  Clinic,  1908. 

7.  Venulet.     Virchow's  Arch,  excvi,  1909. 

8.  DiLLMANN.    Zeitschr.  f.  krebsforsch.  iii,  1905. 

9.  Sternberg.    Zeitschr.  f.  Heilkunde,  1905,  II.  4. 


CHAPTER  XIX 

ENDOTHELIAL  TUMOES 

Endotheliomata. —  The  fact  tliat  endothelial  proliferation  is  con- 
cerned in  tumor  formation  was  first  recognized  by  v.  Recklinghausen^ 
(1862),  and  later  substantiated  by  Koster.-  However,  despite  exten- 
sive research,  the  group  of  cpitheliomata  still  represents  the  most  un- 
certain field  in  the  entire  domain  of  tumor  study.  The  close  relation- 
ship that  endothelium  bears  to  connective  tissue  does  not  permit  of  a 
clear  distinction  from  sarcoma.  Histologically,  certain  endotheliomata 
resemble  epithelial  tumors,  especially  those  arising  from  glandular 
elements,  so  closely  that  the  origin  of  the  cells  is  a  matter  of  dispute 
(e.  g.,  basocellular  carcinoma  cutis,  mixed  tumors  of  the  salivary 
glands,  cholesteatoma,  cylindromata,  etc.)-  In  addition  to  this,  the 
conception  of  the  character  of  endothelium  i;  not  uniform;  it  is,  at 
one  time,  classed  with  connective  tissue,  at  another,  with  epithelium. 
And  last,  but  not  least,  endotheliomata  do  not  possess  any  destructive 
clinical  characteristics. 

The  clinical  diagnosis  of  endothelioma  is,  therefore,  impossible,  and 
the  diagnosis  must  be  made  with  the  microscope.  Yet,  here  too,  a  con- 
clusion is  permissible  onh'  at  the  hands  of  an  expert  pathologist,  who 
is  able  to  exclude  the  various  forms  of  carcinoma,  sarcoma,  and 
adenoma. 

On  the  whole,  endotheliomata  are  rare  tumors.  They  are  divided 
into  lymphangio-endotheliomata,  hemangio-endotheliomata,  and  the 
special  forms  of  peritheliomata  and  dicra-endotheliomata. 

Lymphaxgio-exdotheliomata. — These  spring  from  the  endothelial- 
cells  of  the  lymph  spaces  and  vessels. 

They  present  a  network  of  interlacing  cylindrical  cell  columns  (like 
the  lymphatics)  which  are  composed  of  flat,  cubical  and  short  cylindri- 
cal cells,  and  are  arranged  in  tubules  or  solid  processes.  The  three 
varieties  may  be  found  in  a  single  tumor  or  combined  in  the  same 
microscopical  field.  The  cell  columns  are  enlarged  at  the  nodal  points 
and  the  cells  composing  them  may  be  concentrically  arranged.     The 

1287 


1288 


TUMORS 


cell  columns,  which  differ  widely  in  size,  have  a  delicate  linear  arrange- 
ment and  are  lined  by  a  single  or  double  layer  of  cells  resembling  the 
histological  picture  of  proliferating  lymphatic  vessels.  The  tubules 
may  dilate  and  develop  into  cysts,  the  walls  of  which  present  papillary 
proliferafions;  thus  is  created  a  picture  easily  mistaken  for  cavernous 
and  cystic  lymphangioma  or  papillary  cystadenoma  (Borst^). 

The  connective  tissue  interstitial  tissue  is  developed  in  various  ways. 
It  may  bo  richly  cellular,  mucoid  or  fibrous.  Occasionally,  the  stroma 
undergoes  a  metaplastic  change  into  cartilage  or  into  bone,  which  ex- 
plains the  presence  of  the 
last  two  tissues  in  mixed 
tumors  of  the  salivary 
glands  (p.  1275). 

In  the  skin  and  subcu- 
taneous tissues  (especially 
of  the  face),  lymphangio- 
endotheliomata  form  cir- 
cumscribed, encapsulated 
nodules  or  indefinitely  bor- 
dered infiltrates,  which  are 
usually  regarded  as  sarco- 
mata or,  when  ulcerated,  as 
carcinomata.  They  grow 
slowly  and  rarely  form 
metastases  and  are  there- 
fore regarded  as  compara- 
tively henign  in  character. 

When  neighboring  glands  are  affected,  they  are  usually  soft  and  not 
adherent  to  the  surrounding  tissues  (Tanaka*). 

In  addition,  similar  tumors,  believed  to  be  lymphangio-endothelio- 
mata  which  are  encapsulated,  have  been  found  in  various  organs,  in 
the  membranes  of  the  central  nervous  systems,  in  the  hones,  in  the 
genital  organs,  and  in  the  salivary  glands.  The  last  are  classed  with 
mixed  tumors  by  Wilms,^  and  as  endotheliomata  by  Eibbert.^ 

Endotheliomata  also  occur  (though  rarely)  in  the  pleura  and  peri- 
toneum,  where  they  appear  in  the  form  of  a  thick,  diffuse  infiltrate 
and  extend  into  the  lung  in  the  form  of  large  tumors  and  are  then 
likely  to  form  metastases.  In  this  connection  they  are  classed,  in 
accord  with  the  character  of  the  cell  from  which  they  originate,  with 
the  endotheliomata  or  the  ciarcinomata, 


Fig.  624. —  Lymphangio-Endothelioma. 


ENDOTHELIAL  TUMORS 


1289 


Hemangio-endotheliomata. —  Tumors  of  this  class  originate  from 
the  endothelium  of  blood  vessels. 

The  proliferated  capillaries  and  vessels  of  higher  order,  which  com- 
pose these  tumors,  are  lined  or  completely  filled  with  tall,  proliferating 
endothelial  cells.  Under  the  microscope,  they  appear  in  the  form  of 
gland-like  tuhules  or  solid  columns.  When  the  endothelial  content  is 
similar  to  cubical  or  cylindrical  cells,  the  tumor  is  distinguished  from 
a  glandular  neoplasm  only  by  the  blood  contained  in  the  lumen  of  the 
newly  formed  vessels. 

Tumors  of  this  sort  are  also  characterized  by  their  slow  growth,  their 


Fig.  625. —  Hemangio-endothelioma  of  the  Kidney. 
a.  Blood   vessels   containing   blood;    h,   blood   vessels   filled   with   proliferating 
endothelial  cells   (from  Ziegler's  General  Pathology). 

circumscribed  form,  and  their  moderate  tendency  to  form  metastases. 
They  have  been  found  in  the  various  organs  and  in  the  osseous  system. 
On  section,  the}^  simulate  hemangiomata  or  soft,  exceedingly  vascular 
sarcomata.  In  the  bone,  endotheliomata  cause  the  corticalis  to  thicken 
and,  because  of  their  great  vascularity,  present  a  picture  not  unlike 
that  of  aneurism. 

Peritheliomata. —  Perithelioma  is  a  term  applied  to  a  variet}^  of 
endothelial  tumors,  at  times  classified  with  lymphangio-endotheliomata, 
at  others,  with  the  hemangio-endotheliomata. 

Xhe  origin  of  peritheliomata  varies ;  they  may  spring  from  the  ad- 


1290  TUMORS 

ventitious  cells  of  the  outer  aspect  of  a  blood  vessel  or  from  the  endo- 
thelial cells  of  the  lymph  vessels  that  surround  it.  The  tumor  tissues 
contain  capillary  blood  vessels  which  are  surrounded  by  fnassive  zones 
of  cells  of  various  forms.  These  cell  zones,  perhaps  more  properly 
designated  as  vascular  cell  cylinders,  are  clearly  defined  against  the 
sparse  connective  tissue  stroma  and,  together  with  their  columnar 
arrangement,  impart  a  characteristic  picture  to  the  microscopical  sec- 
tion. Waldeyer^  calls  these  tumors  plexifonn  angiosarcomata.  Kola- 
czek^  uses  the  terra  angiosarcoma;  both  these  terms  should  be  avoided, 
with  the  view  of  obviating  confusion  with  vascular  sarcoma  (Borst'). 
Peritheliomata  resemble  sarcomata  with  pronounced  perivascular 
cell  proliferation  very  closely,  especially  when  the  cell  cylinders  fuse 
into  one  another.  Hyaline  degeneration  and  obliteration  of  the  blood 
vessels  results  in  a  picture  not  unlike  that  of  cylindroma. 

Peritheliomata  are  found  mostly  in  the  hrain  and  meninges,  in  the 
form  of  circumscrihed  ^iodides  or  diffuse  infiltrates  (at  times, 
multiple),  also  in  the  subcutaneous  tissues,  especially  in  the  cheek  and 
the  lower  lip,  the  bone,  the  muscles,  and  the  various  organs.  The 
growth  is  often  found  in  the  carotid  gland,  where  it  appears  as  an  en- 
capsulated tumor  in  the  intercarotid  fork.  It  has  been  found  in  the 
parotid  gland. 

Tumors  of  this  class  are  comparatively  benign. 

DuRA-ENDOTHELiOMATA. — A  Special  form  of  endothelial  tumor  de- 
velops in  connection  with  the  dura  mater.  As  these  tumors  contain 
small  lime  granules,  such  as  are  found  normally  in  the  pineal  gland 
and  on  the  inner  surface  of  the  dura,  they  are  called  psammomata. 

Psammomata  originate  from  the  endothelial  cells  of  the  inner  surface 
of  the  dura  and  form  grayish  red,  circumscribed,  firm  tumors,  at- 
tached by  a  broad  base  or  by  a  pedicle,  that  grow  into  the  brain  (Fig. 
626),  from  which  they  are  separated  by  a  vascular  capsule. 

They  are  usually  single  but  may  be  multiple,  and  vary  greatly  in 
size.  Before  cerebral  symptoms  arise  they  would  have  to  reach  the 
size  of  a  walnut,  and  are  therefore  not  often  discovered  except  incident- 
ally, in  the  course  of  a  routine  postmortem  examination.  As  a  rule, 
tumors  of  this  sort  grow  very  slowly,  though  occasionally  a  particu- 
larly cellular  growth  enlarges  rapidly  and  extends  through  the  dura 
and  even  perforates  the  bone.  Metastatic  dissemination  does  not  occur, 
the  daiigers  of  the  lesion  lying  entirely  in  the  seat  of  the  process. 

The  histological  picture  shows  great  variations  in  the  proportion 
of  cellular  and  connective  tissue  elements.     The  former  are  arranged 


ENDOTHELIAL  TUMORS 


1291 


in  groups  and  columns  consisting  of  flat  or  polymorphous  cells.  The 
columns  interlace  freely  with  the  trabecule  of  the  fibrillary  connec- 
tive tissue,  which  are  richly  supplied  with  blood  vessels.  In  the  micro- 
scopic picture  the  endothelial  elements  appear  in  an  alveolar  or  col- 
umnar arrangement,  within  which  are  a  number  of  bodies  consisting 
of  cells  arranged  in  concentric  layers  like  the  shells  of  an  onion.  By 
the  deposit  of  lime,  these  collections  of  cells  are  converted  into  small 


Fig.  626. —  Endothelioma  of  the  Meninges  Lying  in  a  Depression  in  the 
Surface  of  the  Cerebral  Hemisphere.  (From  MaeCallum's  Text  Book  of 
Pathology.) 

sand  granules.  The  connective  tissue  stroma  may  undergo  hyaline  de- 
generation and  may  also  become  calcified. 

Similar  tumors  are  found  in  the  clural  sheath ^of  the  optic  nerve 
in  the  orbital  cavity  (Ribbert*),  also  in  the  pia  mater,  in  the  pineal 
gland,  the  choroid  plexus,  and  in  multiple  form  in  the  peritoneum 
(Borst^). 

Cylindromata  are  tumors  described  b}^  Koster^  as  consisting  of  endo- 
thelial proliferation  with  hyaline  degeneration  of  the  cell  columns. 

The  growths  contain  small,  vitreous,  hyaline  bodies,  which  are  round, 
club  shaped,  cord-like  or  cylindrical  in  shape,  an4  exhibit  numerous 


1292 


TUMORS 


branches  and  bulbous  protrusions.  They  are  easily  identified  in  the 
sectioned  surface  of  the  tumor.  The  microscopical  picture  is  charac- 
terized by  an  arrangement  peculiar  to  this  class  of  tumors,  i.  e.,  the 
transparent  bodies  are  surrounded  by  a  broad  mantle  of  cells,  and 
when  the  cell  rests  and  fine  fibrillae  are  absent  the  bodies  appear  as 
large  light  lumiua. 

A  similar  histological  picture  is  produced  b}^  In-aline  degeneration 
and  b}'  secretory  processes  in  various  kinds  of  tumors,  so  that  many 
pathologists  (Ziegler,''  Lubarsch,^"  and  others)  do  not  regard  differen- 
tiation as  alwaj's  possible.  This  is  observed  in  connection  with  very 
vascular  sarcomata  in  which  hyaline  degeneration  and  obliteration  of 
blood  vessels  occurs;  in 
adenomata  and  colloid 
carcinomata,  usually  as 
the  result  of  the  secretion 
of  a  colloid  product 
within  the  tubules  of  solid 
cell  columns  or  hyaline 
degeneration  of  the  con- 
nective tissue,  to  which 
the  terms  sarcoma  cylin- 
dromatosum,  carcinoma 
c\jlindromatosum,,  and 
adeno  m  a  cylindroma- 
tosum  have  been  applied. 

However,  these  changes 
take  place  most  often  in 
endotheliomata  and  in 
peritlreliomata,     which 

Bor.st^  regards  as  the  real  cylindromata.  Ribbert^  classifies  cylindro- 
mata  by  themselves,  but  regards  them  as  fibro-epithelial  tumors  orig- 
inating from  mucous  and  allied  glands.  MaeCallum^^  seems  inclined 
to  accept  Eibbert's®  view, 

Cylindromata  grow  very  slowly,  are  encapsulated,  and,  on  section, 
exhibit  hollow  spaces  filled  with  hyaline  masses.  Infiltration  extension 
and  the  formation  of  metastases  are  very  rare,  so  that  it  would  seem 
proper  to  classify  these  lesions  with  the  predominantly  henign  tumors. 
The  hyaline  degeneration  occurs,  in  part,  in  the  interposed  connective 
tissue,  which  is  then  converted  into  irregular  hj^aline  tubules  con- 
taining small  columns  of  cells. 


Fig.  627. — Cylindromatous  Tumor. 


ENDOTHELIAL  TUMORS  1293 

The}'  develop  most  often  in  the  orMt,  the  salivary  glands,  the  palate, 
the  floor  of  the  mouth,  the  antrum  of  Highmore,  and  the  nasal  cavi- 
ties. Occassionally  they  occur  in  the  skin,  the  meninges  of  the  brain 
and  cord,  the  muscles,  the  bone,  and  the  peritoneum. 

A  clmical  diagnosis  based  on  the  symptoms  presented  is  impossible. 
Those  in  the  saJivary  glands  or  palate  closely  resemble  encapsulated 
adenomata  and  mixed  tumors.  When  they  break  through  the  orbit, 
the  nose,  the  jaws,  and  the  frontal  bones  they  are  readily  mistaken 
for  carcinomata  or  sarcomata. 

The  treatment  of  all  endotheliomata  consists  in  extirpation.  The 
encapsulated  form  may  be  enucleated.  When  the  growth  is  infiltrat- 
ing in  character,  a  goodly  sector  of  the  contiguous  tissue  must  also  be 
excised. 

BIBLIOGRAPHY 

1.  V.  Recklinghausen,    v.  Graefe's  Arch.  f.  Opthal.,  Bd.  10,  1864. 

2.  KoSTER.    Virchow's  Arch.  Bd.  40,  1867. 

3.  BoRST.    Die  Lehre  d.  Geschwiilste,  Wiesbaden,  1902. 

4.  Tanaka.     Deutsoh.  Zeitschr.  f.  Chir.,  Bd.  51,  1899. 

5.  Wilms.     Die  Mischgesehwulste,   i-iii,   Berlin   and  Leipzig,   1899,   1900, 

1902. 

6.  Waldeyer.     Quoted  by  Burkhardt,  Beitr.  z.  klin.   Chir.  Bd.  36,  1902, 

with  lit. 

7.  KoLACZEK.     Quoted  by  Burkhardt,  Beitr.  z.  klin.  Chir.  Bd.  36,  1902, 

with  lit. 

8.  RiBBERT.     Geschwiilstlehre,  Bonn,  1908. 

9.  ZiEGLER.     Same  as  No.  6. 

10.  LuBARSCH.     Ergeb.  d.  Allg.  Path.,  1897,  ii. 

11.  MacCallum.     Text  Book  of  Path.,  Phila.,  1916. 


Chapter  XX 

MIXED  TUMORS 

In  a  general  way,  mixed  tumors  consist  of  several  kinds  of  tumor 
tissue.  When  the  combined  forms  of  connective  tissue  tumors  (for 
instance,  fibrolipoma,  osteochondrosarcoma,  lymphangiofibroma)  and 
the  fibro-epithelial  growths,  in  which  the  epithelium  resembles  mucous 
membrane,  skin  or  glandular  tissue,  are  excluded  from  the  field,  the 
mixed  tumors,  which  present  an  extraordinarily  varied  combination  of 
structures,  are  left. 

However,  a  classification  may  be  based  on  a  division  into  simple, 
mildly  complicated,  and  highly  organized  forms,  which  thus  makes 
possible  a  separation  into  three  groups: 

1.  The  simple  mixed  tumors  (of  different  organs). 

2.  Teratoid  tumors  with  two  varieties : 

(a)  Complicated  dermoid   cysts  of  the  ovaries  and  testicle 
(cystic  embryomata  of  Wilms^). 

(b)  Teratoid  mixed  tumors   (embryoid  tumors  of  Wilms^). 

3.  Teratomata. 

SIMPLE  MIXED  TUMORS 

Despite  exhausative  investigation,  the  exact  cause  of  the  develop- 
ment of  this  class  of  tumors  is  still  an  unsolved  problem.  Of  the 
various  theories  in  this  connection,  w-hich  include  that. of  metaplasia, 
metamorphosis  of  fully  developed  tissue,  and  displaced  embryonic 
tissue,  that  of  Wilms^  presents  the  greatest  appeal.  Wilms^  ascribes 
the  ORIGIN  of  THIS  entire  group  of  tumors  to  germinal  tissues  v^hich 

VERY  EARLY,  AND,  THEREFORE,  W^HILE  STILL  IN  THE  UNDEVELOPED  STATE, 
ARE  DISPLACED  AND  ARE  THUS  CAPABLE  OF  IMITATING  THE  DEVELOPMENT 
OF  THE  NORMAL  STRUCTURES  OF  THE  TISSUES  OF  THE  VARIOUS  PARTS  OF 
THE  BODY. 

The  group  of  the  simple  mixed  tumors  includes  those  of  the  salivary 
glands  and  their  surroundings,  the  mammary  glands,  and  the  genito- 

1294 


MIXED  TUMORS 


1295 


urinary  system.  A  part  of  these  growths  are  clinically  very  well 
known.  However,  within  this  group  of  simple  tumors  are  some  of  a 
more  or  less  complicated  nature,  so  that  a  clean  cut  distinction  between 
them  and  growths  of  fibro-epithelial  origin  is  not  always  possible. 

Mixed  Tumors  of  the  Salivary  Glands. —  These  are  most  often  found 
in  the  parotid,  and  occasionally  in  the  submaxillary  gland.  They  ap- 
pear as  clearly  circumscribed  tumors  which  may  develop  at  any  period 
of  life,  but  are  more  common  between  the  ages  of  twenty  and  forty. 
They  grow  very  slowly,  though  at  times  a  tumor  suddenly  and  rapidly 

increases  in  size  and 
may  reach  that  of 
an  adult  head.  The 
growth  is  movable 
upon  the  underlying 
tissues,  while  the 
skin  is  easily  lifted 
from  it  and  is  nor- 
mal in  appearance. 
When  the  growth 
attains  large  dimen- 
sions, the  superim- 
posed skin  may  be 
thinned  out.  As  a 
rule,  the  surface  of 
the  tumor  is  nodu- 
lar, and  firm  in  con- 
sistence ;  occasion- 
ally, certain  sectors 
are  soft  and  impart 
a  sense  of  fluctuation  (pseudofluctuation)  to  the  palpating  finger. 
The  tumor  is  encapsulated  and  originates  from  within  a  lobe  of  a 
salivary  gland  or  is  embedded  in  its  surface.  Occasionally,  a  tumor 
is  pedicled,  and  in  rare  instances  several  tumors  occupy  a  single 
gland. 

Tumors  of  the  parotid,  when  they  develop  from  the  anterior  aspect 
of  the  gland,  make  their  appearance  close  to  the  front  of  the  ear  be- 
tween the  zygoma,  the  anterior  edge  of  the  masseter  muscle,  and  the 
lower  jaw ;  or  they  encircle  the  lobule  of  the  ear,  which  they  elevate 
or  spread  out  when  they  arise  at  the  posterior  portion  of  the  organ. 
Symptoms,  which  arise  only  when  the  tumor  is  large,  consist  in 


Fig.  628. —  Mixed  Tumor  of  the  Parotid  Gland. 


1296 


TUMORS 


lessened  hearing  due  to  obstruction  of  the  auditory  canal,  and  in  par- 
alysis of  the  facial  nerve  from  pressure.  Pain  is  absent.  For  these 
reasons,  the  host  does  not,  as  a  rule,  apply  for  relief  until  the  growth 
attains  considerable  size. 

Suhmaxillary  gland  tumors  fill  the  inframaxilkr-y  region,  and,  when 
the  process  begins  in  the  deeper  portion  of  the  gland,  may  elevate  the 
floor  of  the  mouth. 

The  henign  character  of  a  simple  mixed  tumor  is  attested  by  its  slow, 
expansive  growth,  its  sharply  defined  borders,  and  its  motility.     The 
development  of  malignant  changes  is  indicated  by  sudden,  rapid  in- 
crease in  size  of  the  tumor,  infiltration  of  the  contiguous  tissues,  and 
the  merging  of  the  tumor  outline  into  its  sur- 
roundings.     Submaxillary    tumors    of    this 
sort  become  malignant  in  eleven  per  cent  of 
the  cases  (Kiittner-).    When  this  occurs,  the 
formation    of    lymphogenous    and    hemato- 
genous metastases  occurs  in  the  same  man- 
ner as  in  sarcomata  and  carcinomata,  while 
the  primary  lesion  perforates  its  restraining 
capsule,  invades  and  destroys  the  tissues,  in- 
cluding the  skin,  and  is  soon  converted  into 
an  area  of  deep  ulceration. 

The  diagnosis  of  this  class  of  mixed  tumors 
is  based,  aside  from  their  scat,  upon  their 
slow  growth,  their  nodular  form,  their  varied 
consistence,  and  the 'fact  that  they  are  en- 
capsulated  and  consequently  freely  movable. 
The  advent  of  malignant  changes  is  differen- 
tiated from  sarcomata  and  carcinomata  of  the  salivary  glands  only 
when  the  period  of  benignit}^  has  been  sufiiciently  long  to  make  recog- 
nition of  the  character  of  the  process  possible  during  that  time,  and  to 
note  the  sudden  change  in  the  clinical  picture.  Small  tumors  may 
simulate  tiiberculous  lymph  nodes  and  lipomata.  Cystic  mixed  tumors 
in  the  parotid  gland  may  be  mistaken  for  retention  cysts. 

The  treatment  demands  complete  extirpation  of  the  tumor.  In  the 
encapsulated  forms  this  is  easily  accomplished  without  injury  to  the 
various  branches  of  the  facial  nerve,  and  in  the  submaxillary  gland  is 
best  accomplished  by  enucleating  the  entire  gland.  Recurrences  are 
rare  and  are  ascribable  to  retained  portions  of  the  growth.  Malignant 
tuni&rs  demand  wide  excision,  which  must  not  be  limited  because  of 


Fig.  629. —  Ben'ign  ]Mixed 
Tumor  of  the  Soft  Pal- 
ate. 


MIXED  TUMORS  1297 

the  necessity  of  excising  a  portion  of  the  facial  nerve.  At  best  the 
prognosis  is  not  good. 

Similar,  though  more  simply  constructed,  tumors  are  found  in  the 
cheek  (in  the  vicinity  of  the  parotid  and  submaxillar ij  glands),  which 
originate  from  accessory  glands.  They  are  also  found  in  the  palate 
(Fig.  629),  in  the  upper  Up,  in  the  skin  of  the  nose,  in  the  orbit, 
and  in  the  neighborhood  of  the  lachrymal  gland. 

Macroscopically ,  sections  of  mixed  tumors  of  this  kind  usually  pre- 
sent a  lobulated  arrangement  and  a  mottled  appearance  which  is  pecu- 
liar to  themselves.  Soft  and  hard,  solid  and  cj^stic,  and  variously 
colored  sectors  alternate  with  one  another. 

Microscopically,  the  tumor  is  found  to  consist  of  epithelial  cells  and 
stroma,  both  of  which  appear  in  many  varied  forms  of  arrangement 
and  development,  in  accord  with  the  degree  of  complicated  structures 
of  which  the  tumor  is  made  up. 

The  epithelium-like  cells  are  cubical  and  cylindrical  and  lie  either 
in  solid  cones,  in  alveoli,  or  in  glandr-like  dilated  (cystic)  tubules,  so 
that,  in  some  sectors,  the  specimen  resembles  various  forms  of  adeno- 
mata or  carcinomata.  Wilms^  regards  the.se  glandular  sectors  as  unde- 
veloped imitations  of  the  anlage  of  the  parotid,  submaxillary  or  lach- 
rymal glands.  Camds,  cysts,  and  alveoli  lined  with  flat  epithelium 
(including  basal  layer,  prickle  cells  and  homy  layer  of  the  skin)  are 
found  in  some  of  the  areas  (Hin.<9burg^).  Predominance  of  alveolar 
arrangement  may  produce  the  picture  of  a  squamous  cell  carcinoma. 

The  interstitial  tissue,  consisting  of  fibrillary  or  cellular  embryonic 
connective  tissue,  also  contains  elastic  elements,  which,  in  tumors  with 
complicated  structure,  alternate  with  myxomatous,  cartilaginous,  and 
bony  areas.  Accordingly,  certain  sectors  of  the  stroma  may  resemble 
fibroma,  spindle  cell  sarcoma,  myxoma,  chondroma,  osteoma,  and  os- 
teoid tissue. 

This  explains  the  older  conception,  according  to  which  tumors  of 
this  class  were  designated  as  enchondromata,  eyichondromata  mucosa, 
myxomatodes,  chondrosarcomata,  chondroadenomata,  etc. 

Wilms^  surmises  that  the  varyingly  constructed  interstitial  tissue 
products  of  the  mesenchyme  contain  not  alone  fully  differentiated 
tissue  formations,  but  also  cells  and  classes  of  tissue  in  the  process  of 
development.  As  he  considers  the  gland-like  formations  to  be  an  imita- 
tion of  the  anlage  of  the  respective  glands  they  develop  in,  and  the 
squamous  epithelial  cells  as  derived  from  the  ectoderm  of  the  mouth 
and  orbital  regions,  he  ascribes  the  presence  of  mixed  tumors  of  the 


1298  TUMORS 

salivary  glands,  the  cheek,  the  lip  and  orbit  to  the  unused  residual 
gernmial  tissue  of  the  ectoderm  and  the  mesenchyme.  The  ultimate 
development  of  a  compjicated  or  simple  mixed  tumor  depends  upon  the 
proliferative  capacity  and  the  quality  of  the  individual  elements  in 
the  germinal  complex. 

The  conception  of  other  authors  does  not  agree  with  that  of  Wilms.^ 
Kaufman,*  Borst,^  and  others,  regard  the  mixed  tumors  of  the  sali- 
vary glands  as  endotheliomata  with  atypical  (through  metaplasia)  in- 
terstitial tissue,  and  believe  that  the  columns  of  cells  and  gland  tubules 
are  formed  by  the  proliferation  of  the  endothelium  lining  the  tissue 
spaces  and  lymphatic  vessels.  Ribbert''  and  others  doubt  this.  Rib- 
bert®  classes  these  tumors  with  the  fibro-epithelial  growths  and  believes 
them  to  originate  from  displaced  germinal  glandular  tissue,  the  stroma 
of  which,  because  of  its  relationship  to  the  branchial  arches,  possesses 
skeletogenous  properties,  and  thus  is  capable  of  producing  cartilage 
and  bone.  Hinsberg^  also  believes  that  displaced  germinal  tissue  of 
the  glandular  lobules  of  the  parotid  anlage  and  the  embryonic  perios- 
teum of  the  lower  jaw  are  responsible  for  this  class  of  tumors. 

Mixed  Tumors  of  the  Breast. —  Mixed  tumors  of  the  breast,  according 
to  Wilms,^  are  cystosarcomata  and  adenosarcomata  with  epidermoid 
cysts ;  or  they  are  atheromata  or  cholesteatomata  combined  with  cysto- 
sarcoma  phyllodes.  The  possibility  that  some  of  these  tumors  are 
adenomata,  the  structure  of  which  undergoes  epidermal  metaplasia, 
cannot  be  excluded. 

Clinically,  mixed  tumors  of  the  breast  resemble  adenomata.  They 
are  found  in  women  of  middle  life  and  occasionally  in  men. 

They  appear  as  nodular,  well  defined  tumors,  are  freely  movable, 
and  are  covered  by  normal,  also  movable,  skin.  As  a  rule,  they  de- 
velop comparative!}^  rapidly  and  soon  reach  considerable  dimensions, 
ultimately  breaking  through  the  skin  and  ulcerating.  Metastatic  dis- 
semination does  not  occur. 

The  diagnosis  is  not  easy.  Their  comparatively  rapid  development 
conveys  the  impression  of  an  adenoma  or  a  sarcoma. 

Removal  of  the  entire  breast  is  indicated,  on  the  ground  that  an  exact 
clinical  diagnosis  is  not  possible  and  because  of  the  somewhat  indefi- 
nite nature  of  the  process. 

The  microscope  reveals  a  varying  histological  picture.  A  certain 
sector  of  a  tumor  shows  solid  zones,  while  others  present  hollow  spaces 
and  round  cystic  areas.  Some  portions  are  hard  and  others  are  soft. 
The  picture  is  quite  unlike  that  of  adenomata,  cystadenomata,  or  cys- 


MIXED  TUMORS  1299 

•tosarcoma.  The  tumor  consists  of  adenomatous  tissue,  together  with 
epidermoid  cysts  with  cheesy  contents,  and  cysts  lined  by  squamous 
epithelium.  The  stroma  is  composed  of  mature  embryonic  connective 
tissue  and  contains  large  numbers  of  round  and  spindle  cells,  loose 
mucoid  tissue,  and  cartilaginous  and  osteoid  masses.  Oecasionally 
excessive  proliferation  of  blood  vessels  imparts  an  hemangiomatous 
formation  to  the  growth. 

Wilms '^  conception,  that  these  tumors  originate  from  unused  ecto- 
dermal tissue  —  to  which  some  of  the  mesenchyme  is  attached  — 
inclosed  in  normal  niammaiy  tissue,  would  explain  the  varied  charac- 
teristics of  these  growths,  as  a  nucleus  of  this  sort  would  readilj'  pro- 
duce adenomatous  tissue,  skin,  and  various  forms  of  connective  tissue. 

Mixed  Tumors  of  the  Genito-Urinary  System. —  The  mixed  tumors  of 
the  genito-urinary  S3'stem  are  more  often  malignant  than  those  of  the 
salivary  and  mammary  glands. 

They  occur  most  frequently  in  the  kidney,  where  they  may  be  con- 
genital;  they  are  often  seen  in  young  children,  in  whom  the}'  are  not 
infrequently'  bilateral.  They  usually  develop  ivithin  the  kidney,  the 
substance  of  which  they  displace,  crush  and  destroy.  In  this  way  the 
tumor  develops  into  a  large  nodular  mass  covered  by  the  kidney  cap- 
sule, to  the  inner  side  of  which  a  thin  margin  of  kidnej'  parenchyma 
still  survives.  Ultimateh',  the  new  growth  perforates  the  capsule, 
invades  the  perirenal  tissues,  and  sends  forth  numerous  polypous  pro- 
jections into  the  pelvis  of  the  kidney. 

By  rapid  and  progressive  proliferation,  the  mass  attains  gigantic 
proportions,  filling  the  greater  part  of  the  abdominal  cavit}';  it  ex- 
tends into  the  vena  cava  and  thus  gives  origin  to  numerous  hemato- 
genoiis  metastases,  which  develop  in  all  portions  of  the  body.  Lympho- 
genous metastases  also  develop,  but  these  are  not  as  widely  distributed 
as  are  those  conveyed  by  the  blood  current. 

The  prognosis  is  bad.  Extirpation  of  the  growth  and  the  organ 
containing  it  is  not  followed  by  relief  in  a  large  percentage  of  the 
cases.  This  is  in  part  due  to  the  tendency  the  growth  has  to  recur 
and  the  early  metastases  it  forms,  and  in  part  to  the  general  debility 
of  the  host. 

Macroscopically,  the  sectioned  tumor  is  seen  to  present  a  variated 
picture.  Coarse,  firm  fibrous  areas  alternate  with  vascular  soft  zones 
resembling  the  structure  of  sarcomata. 

The  microscope  reveals  fully  developed,  fihrillary  and  embryonic  con- 
nective tissue   (like  that  of  sarcoma),  mucoid  tissue,  cartilage,  and 


1300  TUMORS 

smooth  and  striated  muscle  fibers  in  various  degrees  of  differentiation. 
The  interstitial  spaces  are  occupied  by  tubular  glands,  which  (as  they 
have  small  cystic  ends  resembling  glomeruli)  are  likely  to  be  mistaken 
for  urinary  tubules.  It  is  these  tubules  that  are  responsible  for  the 
older  terminology  which  designated  the  proeess  as  adenosarcoma, 
adenomyosarcoma,  and  adenomyochondrosarcoma. 

Occasionally,  typical  squamous  epithelium  with  cornification  ar- 
ranged in  irregular  groups,  together  with  cholesterin-like  masses,  are 
found  in  the  hollow  spaces. 

The  origin  of  these  tumors  is  ascribed  to  developmental  anmnalies 
in  the  formation  of  the  kidney.  Wilms^  holds  that  these  occur  early 
in  embryonic  life  and  submits  that,  if  this  were  not  true,  one  would 
have  to  assume  the  simultaneous  displacement  of  a  number  of  kinds 
of  tissue  to  account  for  the  variety  of  tumors  found  in  the  tumor  mass. 
He  regards  the  tumor  as  arising  from  a  displaced  germinal  mesoderm 
originating  from  the  zone  of  the  primitive  kidney.  The  morphology 
of  mixed  tumors  of  tlie  kidney  is  extensively  discussed  by  Hedren.'^ 

Mixed  tumors  of  the  vagina  appear  in  young  children  in  the  form 
of  polypous  grape-like  tumors.  They  also  appear  in  fniddle  life  in  the 
cervix  nderi,  where  they  grow  rapidly,  fill  the  vagina,  protrude  from 
the  vulva,  and  infiltrate  the  connective  tissue  of  the  pelvis.  Both 
forms  are  very  likely  to  recur,  disintegrate,  and  cause  death  in  a  few 
years.     Metastases  are  rare. 

Histologically,  these  tumors  are  composed  of  different  forms  of  sar- 
coma tissue,  together  with  striated  muscle  fibers,  cartilage,  and  mucoid 
ayid  fatty  tissues.  They  may  also  be  accounted  for  on  the  basis  of 
Wilms^  theory,  which  places  them  with  the  tumors  arising  from  dis- 
placed embryonic  tissue  of  the  mesoderm. 

V.  Amman®  furnishes  the  literature  with  extensive  representations 
in  this  connection.  Fig  592  shows  a  peculiar  development  of  tumors 
of  the  vagina  and  pelvic  connective  tissue,  designated  as  rhabdomyo- 
mata,  but  these  would  seem  to  be  more  properly  classed  with  the  mixed 
tumors,  a  viewpoint  MacCallum^  shares.  The  reader  is  advised  to 
consult  the  section  of  the  work  referred  to,  with  the  view  of  elucidating 
the  subject. 

A  similar  condition  of  affairs  obtains  in  mixed  tumors  of  the  urinary 
bladder,  which  appear  as  polypoid  growths  in  the  region  of  the  trigone. 
Wilms^  ascribes  these  also  to  displaced  cells  of  the  mesoderm.  He 
attributes  a  similar  genesis  to  mixed  tumors  appearing  in  the  lower 
pole  of  the  testicle  (vas  deferens)  in  young  children.     These  are  also 


MIXED  TUMORS  1301 

(probably  erroneously)  designated  as  rhahdomyamata  or  rhahdomyo- 
sarcomata. 

Hlisler^"  would  seem  to  have  cleared  up  the  atmosphere  to  a  con- 
siderable extent  in  this  class  of  cases  (see  bibliography) .  On  the  other 
hand,  Eibbert®  suggests  that  mixed  tumors  of  the  urogenital  sj-stem, 
which  appear  in  definite  situations,  may  be  ascribable  to  the  early 
wandering  of  separated  germinal  cells  into  the  kidney  zone  and  their 
passage  through  Mliller's  and  the  wolffian  ducts  into  the  uterus  and 
vagina,  the  urinary  bladder,  and,  perhaps,  into  the  vas  deferens. 

BIBLIOGRAPHY 

1.  "Wilms.     Die  Mischgeschwiilste,   i-iii,   Berlin   and  Leipzig,  1899,  1900, 

1902. 

2.  KuTTXER.    Beitr.  z.  klin.  Chir.,  Bd.  16,  1896. 

3.  HiNSBERG.     Deutsch.  Zeitschr.  f.  Chir.,  Bd.  51,  1899. 

4.  KAUFiiAXX.     Arch.  f.  klin.  Chir.,  Bd.  26,  1881. 

5.  BoRST.    Die  Lehre  d.  Gesehwiilste,  Wiesbaden,  1902. 

6.  RiBBERT.     Gescliwiilstelehre,  Bonn,  1908. 

7.  Hedren.     Ziegler's  Beitr.,  1907,  xl. 

8.  v.  Ammaxx.     Arch.  f.  G^^lakol.,  Bd.  82,  1908. 

9.  MacCallum.     Text  Book  of  Path.,  Phila.,  1916. 
10.  HiJSLER.    Jahrb.  f .  kinderheilk.  Bd.  62,  1905,  ii. 


CHAPTER  XXI 
TERATOID  TUMORS 

Complicated  Dermoid  Cysts  of  the  Ovaries  and  Testicles  —  Wilms' 
Cystic  Embryomata. —  Teratoid  tumors  are  henign  growths  which 
resemble  the  simple  dermoid  cysts,  except  that,  instead  of  containing 
only  skin  follicles  with  hair,  glands,  and  cheesy  matter,  they  are  also 
provided  with  large  bundles  of  hair,  teeth,  and  particles  of  bone  in 
their  walls ;  a  much  more  complicated  structure  than  obtains  with 
simple  cysts. 

Complicated  Ovarian  Cysts. —  Nine  per  cent  of  ovarian  tumors 
are  of  this  class.  They  are  found  more  often  in  the  adult  than  in  the 
new  horn,  though  no  doubt  they  are  also  congenital.  They  develop  in 
one  or  both  ovaries,  within  or  upon  the  surface  of  the  organ,  where 
they  are  often  pedunculated,  and  at  times,  when  the  pedicle  separates, 
they  may  be  free  in  the  abdominal  cavity.  Tumors  of  this  nature 
situated  in  other  portions  of  the  body  may  also  arise  from  super- 
numerary ovarian  tissues. 

As  a  rule,  they  grow  slowly  but  often  reach  the  size  of  the  adult 
head.  As  growth  proceeds  the  ovarian  tissue  is  gradually  destroyed. 
Occasionally,  rupture  of  the  cyst,  which  liberates  cell  groups  capable 
of  germination,  is  followed  hy  the  development  of  numerous  small 
cysts  on  the  surface  of  the  peritoneum.  A  certain  number  of  cysts 
give  origin  to  squamous  epithelial  carcinoma. 

Symptoms  are  produced  when  the  growth  reaches  a  certain  size  and 
are  due  to  pressure  upon  the  Madder  and  rectum,  and  to  secondary 
disturbances  which  involve  considerable  danger.  A  pedunculated  cyst 
is  often  robbed  of  its  nourishment  by  the  twisting  of  its  pedicle;  this  is 
followed  by  disintegration  of  the  cyst  wall,  rupture,  and  peritonitis. 
Again,  the  cyst  may  become  adherent  to  the  gut,  bladder  or  rectum, 
and  may  establish  communication  with  them.  This  is  soon  followed  by 
putrefactive  inflammation,  and  a  fatal  outcome  ensues.  Ovarian  der- 
moids must  be  differentiated  from  other  tumors  in  this  region ;  not  an 
easy  problem. 

1302 


TERATOID  TUMORS 


1303 


The  treatment  consists  in  extirpation  of  the  tumor,  together  with  the 
organ  it  arises  from. 

Complicated  Dermoid  Cysts  op  the  Testicle.—  Tumors  of  this  sort 
are  rare.     They  are  found  more  often  in  small  children  than  in  the  adult 


hW^>A:>W- 


'i-'"m^ 


"^ 


.■ir< 
^1 


Fig.  630. —  Contents  of  a  Dermoid  Cyst  op  the  Ovary   (Kelly). 


and  are  often  congeniial.  Occasionally,  they  develop  in  the  inide- 
scended  testicle.  They  may  appear  in  both  testicles,  but  this  is  unusual. 
As  a  rule,  they  develop  in  the  substance  of  the  organ,  of  which  little 


1304  TUMORS 

normal  structure  remains.  The  occurrence  of  a  dermoid  outside  the 
testicle  (in  the  scrotum)  is  very  rare. 

The  growth  of  complicated  dermoids  in  this  situation  is  very  slow. 
They  provoke  symptoms  because  of  their  size  and  never  produce  the 
grave  disturbances  attendant  upon  similar  tumors  of  the  ovarj\ 

The  ''doughy  feel"  of  the  tumor  aids  in  differentiating  it  from  other 
tumors  of  the  testicle. 

The  treatment  consists  in  extirpation  of  the  affected  organ. 

The  peculiarity  of  complicated  dermoid  cysts  of  the  genital  organs 
(according  to  Wilms^)  consists  in  the  rudimentary  em'bryoiic  o/nlage 
which  these  tumors  contain  {therefore,  cystic  emhryomata). 

The  sac  wall  is  firm  and  not  of  uniform  thickness.  The  inner  surface 
is  clothed  with  fully  developed  skin,  of  which  a  certain  zone  protrudes 
in  the  form  of  a  tumorous  thickening .  Another  presents  a  number  of 
villi,  while  another  consists  of  an  area  of  nodular  thickening.  The 
cavity  of  the  cyst  is  often  divided  by  one  or  more  partitions.  The 
projections  are  also  covered  by  hairy  sJiin  and  contain  teeth  which  are 
connected  with  portions  of  hone  buried  in  the  cj^st  wall.  The  cyst  wall 
contains  derivatives  of  three  germinal  layers ;  not,  however,  in  the 
irregular  mixture  of  teratoid  mixed  tumors,  but  arranged  in  unmistak- 
able imitation  of  the  head  segment  of  an  embryo  (Wilms^),  while  the 
tissue  beneath  the  skin  layer,  consisting  of  subcutaneous  fat,  cartilage, 
bone  and  muscle,  also  contains  lirain  substance,  together  with  corpora 
amylacea.  In  addition  to  this,  a  certain  portion  of  the  tumor  consists 
of  mucous  membrane  covered  with  squamous  epithelium  and  is  provided 
with  a  canal  lined  by  cylindrical  and  ciliated  epithelial  cells.  Some 
of  the  cysts,  the  walls  of  which  contain  cartilage  rings  and  interstitial 
muscle  fibers,  resemble  in  structure  the  respiratory  passages;  while 
others,  lined  with  goblet  cells  and  filled  with  mucus,  resemble,  histo- 
logically, the  intestinal  tract.  To  this  may  be  added  (without  much 
imagination)  various  other  tissue  formations,  such  as  anlage  of  the 
eye,  thj^roid,  trachea,  mammary"  gland,  etc.  The  greater  part  of  the 
cyst  is  lined  with  skin,  the  rest  with  cylindrical  epithelium  or  granula- 
tion tissue. 

In  a  given  tumor,  the  embryonic  tissues  and  organs,  which  develop 
earliest,  predominate,  viz.,  ectoderm  and  the  tissues  and  organs  of  the 
head,  so  that  the  different  component  parts  of  the  tumor  vary  to  a 
considerable  extent,  some  being  destroyed  by  the  rapidity  of  growth 
of  the  others  (Wilms^). 

The  origin  of  complicated  dermoid  cysts  (embryomata)  of  the  gen- 


TERATOID  TUMORS  1305 

ital  organs,  like  that  of  the  teratoids  (embryoids),  is  a  matter  of  dis. 
pute.  Waldeyer-  suggests  an  abnormal  proliferation  of  the  cells  of 
the  ovum  and  of  the  spermatozoa,  which  occurs  without  fertilization 
(parthenogenesis).  This  is  disputed  by  Bonnet,^  who  ascribes  their 
origin  to  unused  residual,  polar  globules  (blastomeres)  or  to  the  fer- 
tilization of  a  polar  globule  simultafieously  with  the  ripe  egg,  and  holds 
that  the  tumor  mother  cells  gain  access  to  the  embryonic  glandular 
anlage  and  thus  create  atypical  development  in  this  situation.  Mar- 
chand*  and  Wilms^  are  inclined  toward  the  theory  of  the  development 
of  tumors  of  the  genital  organs  from  blastomeres,  as  the  observation 
that  five  and  seven  embryomata  have  developed  in  a  single  ovary  can- 
not be  reconciled  to  their  development  from  polar  cells,  because  the 
human  ovum  usually  possesses  only  two  or,  at  the  most,  three,  polar 
cells  (Askanazy"). 

According  to  this  theory,  these  tumors  are  composed  of  the  three 
layer  germinal  anlage,  which  originates  from  the  displaced  blastomeres. 
This  conception  of  the  method  of  development  'applies  not  only  to  the 
complicated  dermoid  cysts  of  the  generative  organs,  but  also  to  the 
teratoid  mixed  tumors.  The  remaining  teratoid  tumors  and  teratomata 
are  also  ascribed  to  blastomeres  or  to  fertilized  polar  globules.  The 
genetic  relationship  of  these  tumors  with  the  ovaries  is  shown  by  the 
fact  that  complicated  ovarian  dermoids,  without  amy  original  connec- 
tion with  these  organs,  appear  in  the  abdominal  cavity.  "Why  the 
growth  of  the  germinal  anlage  results  in  such  a  variety  of  develop- 
ments is,  however,  not  clear.  Debemardi®  and  Chevassu'^  devote  much 
anal^-tical  effort  to  the  subject  (see  bibliography). 

Teratoid  Mixed  Tumors. —  The  tumors  in  this  group  differ  from  com- 
plicated dermoids  in  their  solid  and  polycystic  structure,  and  from 
teratomata  by  the  absence  of  highly  developed  rudiments.  They  are 
formed  as  the  result  of  the  irregular  proliferation  of  derivatives  of 
the  three  germinal  laj^ers  (Tridermoma  of  Wilms^)  and  they  present 
a  much  more  varied  composition  than  the  simple  mixed  tumors. 

They  appear  in  all  portions  of  the  body  where  teratomata  are  found, 
but  are  most  frequently  met  with  in  the  testicle  and  ovary. 

Teratoid  Tumors  of  the  Testicle. —  Mixed  tumors  of  the  testicle 
appear  betw^ecn  the  twentieth  and  fortieth  year  of  life.  They  grow 
slowly,  forming  large  nodular  tumors  of  irregular  form  and  consistence 
and  gradually  occupy  the  entire  affected  organ.  In  a  comparatively 
large  number  of  instances,  they  become  malignant.  Ultimately,  active 
proliferation   of   sarcomatous   or   adenocarcinomatous   tissue   breaks 


1306  TUMORS 

through  the  capsule  (which  is  formed  by  the  tunica),  infiltrates  the 
neighboring  tissues  and  leads  to  the  formation  of  numerous  metastases. 
The  character  of  the  latter  usually  corresponds  only  to  the  malignant 
structure  of  the  primary  growth,  but  may  be  similar  in  structure  to 
the  three  laj'crs  of  germinal  tissue. 

The  diagnosis  is  assisted  by  taking  into  consideration  the  slow  growth 
of  the  tumor  and  its  irregular  consistence.  The  malignant  forms  can- 
not be  differentiated  from  sarcomata  and  carcinomata  of  the  testicle. 

In  accord  with  their  dominant  constituent,  these  tumors  have  been 
designated  as  testicular  chondromata,  adenocystomata,  adenomyosarco- 
mata,  cystocarcinomata,  etc.  However,  Wilms,^  whose  statements  in 
this  connection  would  seem  worthy  of  consideration,  has  shown  that 
derivatives  of  the  three  germinal  layers  are  almost  always  present, 
even  though  those  of  the  ectoderm  and  mesoderm  predominate  and 
the  ectodermal  may  be  absent.  The  different  tissues  lie  in  incodrdi7iate 
confusion.  The  basic  structure  is  composed  of  embryonic  and  mature 
forms  of  connective  tissue,  of  mucous  and  fatty  tissue,  of  cartilage 
and  bone,  of  smooth  and  striated  muscle  fibers,  and  tissues  of  the  peri- 
pheral and  central  nervous  system,  together  with  glandular  elements 
which  are  arranged  in  the  form  of  clefts  and  cysts  lined  by  various 
kinds  of  epithelium.  Not  infrequently,  the  mucous  membrane  portion 
of  the  tumor  shows  a  tendency  to  conform  to  the  normal  and  presents 
an  appearance  not  unlike  that  of  the  mouth,  the  pharynx,  and  the  gut. 

Teratoid  Mixed  Tumors  of  the  Ovary. —  These,  like  complicated 
dermoid  cysts,  develop  wathin  the  organ  and  on  its  surface.  They  are 
most  likely  to  appear  at  adolescence,  and  are  less  frequently  met  with 
than  the  dermoids,  but  may  occur  simultaneously  with  them.  Like 
teratoid  tumors  of  the  testicle,  they  grow  slowly  as  long  as  their  tissues 
do  not  develop  malignant  characteristics. 

Histologically,  these  tumors  also  represent  derivatives  of  the  three 
germinal  layers,  occasionally  showing  an  accelerated  development  of 
embryonic  rudiments,  especially  of  the  head  segment,  in  a  manner 
similar  to  that  which  obtains  in  connection  with  complicated  dermoid 
cysts. 

Teratoid  mixed  tumors  also  appear  in  the  mouth,  the  pharynx,  and 
the  nasal  cavities  in  the  form  of  polypi  covered  with  hair  (Arnold*)  ; 
in  the  skull  (in  the  ventricles  or  at  the  base  of  the  brain  in  the  hypo- 
physis) ;  in  the  neck  and  the  thorax  (in  the  mediastinum,  within  the 
pericardium)  ;  in  the  abdomen  (at  the  mesocolon  and  transverse  colon, 
in  the  bursa  epiploica,  in  the  mesentery  of  the  ilium  or  retroperi- 


TERATOID  TUMORS  .  1307 

toneally  in  the  left  side  near  the  spinal  column,  the  result  of  the 
adherence  of  the  embryonic  peritoneum  to  the  posterior  wall  of  the 
abdomen  and  because  of  displacement  of  the  fetal  organs,  Lexer")  ;  and 
in  front  or  behind  the  sacriun  and  coccyx. 

These  tumors  should  be  removed,  an  accomplishment  often  difficult 
of  attainment. 

Teratoid  mixed  tumors  are  often  congenital  or  appear  in  early  child- 
hood, though,  occasionally,  they  are  developed  in  adult  life.  They 
form  encapsulated  nodular  tumors  of  irregular  outline  and  consistence. 
Their  location  is  of  help  in  the  diagnosis. 

Their  origin  is  similar  to  that  of  teratomata,  which  they  resemble 
very  closely,  except  that  they  are  composed  of  less  highly  developed 
tissues. 

BIBLIOGRAPHY 

1.  Wilms.     Die  Misc-hgeschwiilste,  Berlin  and  Leipzig,  1899,  1900,  1902. 

2.  "Waldeyer.     Quoted  by  Wilms  No.  1. 

3.  BoxxET.     Quoted  by  Wilms  No.  1. 

4.  ]\Iarchaxd.     Eulenberg's  Realenzyklop.  Bd.  25,  1899. 

5.  AsKAXAZY.     Verb.  d.  path.  Gesel.,  1907;    also  Wiener,  med.  Woch.,  1909, 

No.  43. 
8.     Deberxadi.     Ziegler's  Beitr.,  1908,  xliii. 

7.  Chevassu.     Tumoi-s  du  testicle,  Paris,  1906. 

8.  Arxold.     Vircbow's  Arcb.  Bd.  iii,  1888. 

9.  Lexer.     Arcb.  f.  klin.  Cbir.,  Bd.  61,  1900,  with  lit.,  and  Bd.  62,  1900. 


CHAPTER  XXII 

TEKATOMATA 

Teratomata  constitute  the  transition  between  teratoid  mixed  tumors 
and  the  double  malformations,  such  as  a  fetus  within  a  fetus.  They 
stand  on  the  borderline  between  new  growths  and  malformations.  On 
the  other  hand,  one  might  say  that  a  portion  of  the  double  formations 
develop  in  the  form  of  a  tumor. 

Teratomata  are  alwa^^s  congenital  and  are  located  cither  7iear  the 
surface  of  the  body  (as  they  are  when  connected  with  the  base  of  the 
skull  and  located  in  the  oral  cavity,  etc.)  or  in  the  cavUies  of  the  hody 
(thorax  and  abdomen). 

They  are  often  large  when  the  child  is  born  or,  when  the  child  sur- 
vives (which,  fortunate!}^,  is  not  often),  they  grow  to  great  dimensions. 

The  form  of  teratomata  varies  greatly,  though  most  of  them  are 
nodular  and  irregular.  The  consistence  of  their  various  sectors  also 
varies ;  some  are  cystic,  and  some  solid,  as  embryonic  rudiments  alter- 
nate with  mucous  and  fatty  tissues.  They  are  usually  inclosed  in  a 
firm  capsule,  which  is  sharply  defined  against  the  surrounding  tissues 
and  gives  entrance  to  rather  good  sized  blood  vessels.  In  the  abdomen 
teratomata  may  be  inclosed  in  an  amniotic  sheath  (Fig.  631).  On  the 
surface  of  the  body  the  skin  furnishes  a  sacculated  covering. 

The  presence  of  fully  developed  fetal  rudiments  differentiates  terato- 
mata from  mixed  tumors,  although  a  clear  line  of  demarcation  in  this 
connection  is  not  established.  Teratomata  contain  incompletely  devel- 
oped sections  of  the  skeleton,  such  as  bones  of  the  skull,  the  jaws,  the 
fingers  or  the  toes,  loops  of  gut  wnth  a  mesenteric  cyst  resembling  a 
stomach,  lungs,  kidneys,  thyroid  glands,  pancreatic  tissue,  brain  sub- 
stance with  convolutions  and  ventricles,  bronchi,  nerves,  rudimentary 
eyeballs,  etc.  Those  covered,  in  part,  by  skin  protrude  like  a  dermoid 
cavity  or  are  surrounded  by  an  amnion-like  sheath.  These  constituents, 
with  the  other  rudimentary  parts,  are  bound  together  in  a  tumor  mass 
similar  to  teratoid  mixed  tumors. 

The  growth  conveys  the  impression  of  the  cells  of  an  embryonic 

1308 


TERATOMATA 


1309 


anlage  indiscriminately  thrown  together  and  as  though  part  of  them 
had  been  destroyed.  The  surviving  portions  appear  to  have  gone  on 
to  dwarfish  development  of  normal  parts  and  organs  of  the  body  with- 


FiG.  631. —  A  Teratoma  the  Size  of  a  Fist  Kemoved  from  a  Girl  Baby  Seven 
Weeks  Old,  by  Operation. 

The  tumor  lay  in  the  foramen  of  Winslow  just  beneath  the  liver  and  was 
adherent  to  the  hepatoduodenal  ligament,  from  which  its  nutrient  vessels  were 
derived  (Lexer).  ],  The  pedunculated  sac  of  skin  contains  an  anlage  of  the 
head,  consisting  of  brain  cavities,  connective  tissue  skull,  well  developed  scalp, 
an  anlage  of  teeth  extending  into  the  pedicle,  and  squamous  cell  epithelium,  which 
resembles  that  of  the  mouth.  2,  Capsule  of  the  tumor  open.  Sa,  Point  of  attach- 
ment of  tumor.  The  tumor  also  contains  a  cyst  situated  close  to  the  anlage  of 
the  head,  which  is  provided  Avith  ciliated  epithelium  and  goblet  cells,  mucous 
glands,  smooth  muscle  fibers,  and  hyaline  cartilage  (anlage  of  the  respiratory 
passages).  The  principal  part  of  the  nodular  tumor  is  a  teratoid  (polycystic) 
mixed  tumor.    H^,  Ho,  Nodules  of  skin  attached  to  the  head  anlage. 


1310  TUMORS 

out,  however,  any  regard  to  localization,  while  some  simply  attain 
imitation  of  various  tissues. 

The  diagnosis  of  teratomata  rests  on  their  seat.  Those  located  super- 
ficially or  in  typical  situations  are  more  readily  recognized  than  those 
inclosed  in  cavities,  of  which  tumors  of  the  thorax  cannot  be  diagnosti- 
cated. Teratomata  in  the  abdominal  cavity  may  be  palpated,  and 
when  they  contain  teeth  and  bone  may  be  detected  by  means  of  the 
X-ray  plate. 

The  operative  extirpation  of  teratomata  has  been  accomplished,  but 
is  not  likely  to  be  followed  by  recovery  (Kleinwachter,^  Lexer^). 

The  origin  of  teratomata  is  not  the  same  in  all  instances.  Those  of 
the  caudal  and  cephalic  extremities  arise  in  the  course  of  development 
of  displaced  germinal  layers  or  from  embryonic  rests  that  have  not 
undergone  regression ;  others  develop  from  embryonic  rudiments  and 
resemble  malformations  so  closely  that  they  suggest  inclusion  of  a 
second  fetal  anlage  (bigerrdinal  teratoma  or  fetal  inclusion ;  parasitic 
implantation,  parasitic  fetus  in  fetus).  However,  the  assumption  of 
a  second  fertilized  anlage  upon  the  same  germinal  vesicle  (Ahlfeldt^) 
is  difficult  to  accept  because  of  the  intra-amniotic  location  of  the  tera- 
toma nucleus  (Marchand*).  Per  contra,  the  theory  that  teratomata 
spring  from  fertilized  polar  globules  presents  a  rational  basis 
(Marchand,*  Bonnet'').  Additional  authoritative  work  is  presented 
by  Borst,®  Nasse,^  Otto,^  and  Hunziker.® 

BIBLIOGRAPHY 

1.  Kleinwachter.     Zeitschr.  f.  Heilkunde,  ix,  1888. 

2.  Lexer.     Arch.  f.  klin.  Chir.,  Ixi,  1900,  with  lit.;   also  Ixii,  1900. 

3.  Ahlpeldt.     Quoted  by  Wilms :  Die  Mischgeschwiilste,  Berlin  and  Leip- 

zig, 1899, 1900,  1902. 

4.  Marchand.    Eulenberg's  Realenzyklop.  xxv,  1899. 

5.  Bonnet.     Same  as  No.  3. 

6.  BoRST.    Die  Lehre  d.  Gesehwiilste,  Wiesbaden,  1902. 

7.  Nasse.     Arch.  f.  klin.  Chir.,  xlv,  1893. 

8.  Otto.     Virchow's  Arch,  cxv,  1899. 

9.  Hunziker.    Beitr.  z.  Gebuntsch.  and  Gyn.  xiii,  1909. 


PART  VII 

CYSTS 
{Excluding  Cystic  Tumors) 


CHAPTER  I 
CYSTS  OTHER  THAN  CYSTIC  TUMORS 

A  cyst  is  an  entirely  closed  sac,  the  contents  of  which  may  be  a  thin 
or  a  thick  fluid,  or  of  a  pasty  consistence.  Cysts  with  one  cavity  are 
called  unilocular,  those  with  many  cavities  are  called  multilocular. 
They  are  generally  globular  in  shape,  but  may  be  deformed  by  the 
pressure  of  the  surrounding  tissues  to  which  they  conform,  or  as  the 
result  of  adhesions,  or  they  ma}^  be  the  shape  of  the  original  cavity  of 
a  hollow  organ  or  part. 

Aside  from  the  cysts  which  develop  in  true  tumors  as  the  result  of 
their  structural  peculiarities  (embrj^onic  cysts,  etc.),  or  because  of 
regressive  changes,  there  are  a  number  of  cysts  which  have  nothing  to 
do  with  genuine  tumor  formation. 

In  accord  with  the  character  of  the  underlying  process,  four  varie- 
ties of  cysts  may  be  estaiblished  which  include  true  or  false  cysts, 
depending  upon  whether  their  walls  are  lined  with  epithelium  or 
endothelium,  or  are  devoid  of  a  lining. 

Exudation,  or  Extravasation  Cysts. —  An  exudate  or  the  extravasation 
of  Mood  may  occupy'  a  hollow  space,  already  present,  or  one  created 
by  a  pathological  process. 

A  hydrocele  of  the  tunica  vaginalis  or  of  the  spermatic  cord  is  a 
good  example  of  an  exudation  cyst.  The  closure  of  the  central  end  of 
the  vaginal  process  is  followed  by  a  chronic  inflanunatory  process  which 
is  attended  by  the  formation  of  a  watery  exudate.  In  hygromata  — 
cysts  of  the  bursae  and  tendon  sheaths  —  the  serous  or  hemorrhagic 
exudate  is  also  formed  in  previously  existing  hollow  spaces.  In  the 
same  sense,  ascites,  articular  hydrops,  and  hydrocephalus  might  be 
classed  with  the  cj'sts;  however,  here  the  anatomical  conditions  are 
not  those  of  a  cj^st.  On  the  other  hand,  an  empty  hernial  sac  may  be 
closed  against  the  abdominal  cavity  or  a  meningocele  against  the 
cranium  and,  because  of  the  obstruction  to  the  exit  of  fluids,  maj^  be 
converted  into  a  cyst. 

A  hematocele  is  caused  by  the  exudation  of  blood  into  the  tunica 

1313 


1314  CYSTS 

vaginalis  testis.  The  effusion  consists  partly  of  fluid  and  partly  of 
friable  blood,  while  the  wall  of  the  sac  is  lined  with  fibrin  and  pro- 
liferated connective  tissue. 

Traumatic  hlood  cysts  are  caused  by  bleeding  into  spaces  between 
the  stumps  of  subcutaneously  torn  muscles  or  into  the  meshes  of  sub- 
cutaneous tissue  crushed  by  blunt  force.  The  zone  of  the  bloody 
exudate  is  surrounded  by  a  layer  of  proliferated  connective  tissue, 
while  the  torn  tissues  are  gradually  absorbed. 

Pneumatocele  cranii,  though  in  no  sense  a  cyst,  possesses  some  of 
the  characteristics  of  the  latter  and  is,  therefore,  mentioned  in  this 
connection.  It  consists  of  a  collection  of  air  between  the  periosteum 
and  the  bone  and  occurs  at  the  forehead,  where  it  communicates  with 
the  frontal  sinus,  and  in  the  occipital  region  behind  the  ear,  where  it  is 
in  connection  with  the  small  perforations  in  the  mastoid  process.  The 
tympanitic  note  elicited  on  percussion,  and  the  increase  in  size  of  the 
tumor  upon  expiratory  pressure,  make  the  diagnosis.  Incision  and 
tamponade  allow  the  granulations  to  close  the  opening.  It  may,  how- 
ever, bo  necessary  to  resort  to  closure  of  the  defect  by  osteoplastic 
methods  (v.  Bergmann^). 

Multiple  gas  cysts  of  the  intestinal  serosa  {pneumatosis  cystoides 
intestinalis)  has  been  described  b}^  Mori,^  who  ascribes  the  condition  to 
infection  of  the  lymph  spaces  by  the  gas  bacillus,  a  view  Miyake' 
contests. 

Liquefaction  Cysts. —  Liquefaction  cysts  are  hollow  spaces  in  normal 
tissue,  the  result  of  nutritive  disturbances.  They  are  filled  with  thin 
fluid  or  colloid  masses  and  have  walls  composed  of  proliferated  connec- 
tive tissue.    Similarl}',  cysts  are  often  formed  within  true  tumors. 

To  this  class  of  cysts  belong  ischemic  softening  of  the  hrain  and  the 
well  known  colloid  cysts  of  the  ligaments  of  the  joints  (ganglia)  which 
are  closely  related  to  hygromata  of  the  bursae  (p.  972).  At  times  the 
contents  of  an  infective  abscess  undergoes  liquefaction  and  a  cyst  of 
this  kind  is  formed. 

Retention  Cysts. —  When  the  duct  or  opening  of  a  gland  or  cavity  is 
ohstructed  so  that  fluid  secretions  collect  and  dilate  their  spaces,  a 
so-called  dilatation  or  retention  cyst  is  formed.  Under  these  circum- 
stances the  irritation  of  the  retaining  wall  causes  it  to  thicken  and 
dilate  beyond  the  limit  of  its  physiological  capacity. 

Cysts  of  this  kind  develop  in  connection  with  hollow  organs,  glands 
and  hlood  vessels. 

Ketention  Cysts  of  Hollow  Organs. —  Cystic  enlargement  of  a 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1315 

hollow  organ  from  obstruction  of  its  exit  is  often  seen  in  connection 
with  the  gallbladder.  When  the  cystic  duct  is  obstructed  by  an 
incarcerated  stone,  or  by  cicatricial  contraction,  the  gallbladder  is 
filled  with  the  mucous  secretion  from  its  walls;  the  contents  undergo 
secondary  changes  and  convert  the  organ  into  a  large  cucumber  shaped 
formation  (hydrops  vesicae  felleae.  Fig.  632).  A  similar  condition 
of  affairs  occurs  in  the  appendix  vcrmiformis  when  its  cecal  end  is 
obstructed  by  scar  tissue,  which  causes  it  to  dilate  to  the  size  of  a  pear 
{hydrops  processus  vcrmiformis) .  However,  this  condition  is  seen 
most  frequently  in  the  fallopian  tubes  when  both  the  uterine  and 
distal  ends  are  occluded.  This,  in  accord  Avith  their  content,  leads  to 
the  development  of  hydrops  tuharum,  pyosalpinx  or  hemosalpinx.  An 
additional   example  of  this  class  of  CA'st  formation  is  presented  in 


Fig.  632. —  Hydrops  of  the  Gallbl^vdder   (one  half  natural  size). 
A  gallstone  may  be  seen  showing  through  the  beginning  of  the  cystic  duct. 

hydronephrosis,  in  which,  when  the  ureter  is  obstructed  as  the  result 
of  congenital  malformation,  torsion,  or  cicatricial  contracture,  or  by 
an  incarcerated  stone,  the  flow  of  urine  is  intermittently  or  perma- 
nently interfered  with,  and  the  pelvis  of  the  kidney  is  dilated  to  such 
an  extent  as  to  cause  complete  obliteration  of  the  renal  parenchyma. 

Retention  Cysts  of  Glands. —  Retention  cysts  of  glands  develop 
either  in  their  ducts  or  in  the  glands  themselves. 

Atheromata  {sebaceous  cysts)  are  retention  cysts  of  the  skin. 
Either  the  duct  of  the  sebaceous  gland  opening  into  the  hair  follicle 
or  the  hair  follicle  itself  is  obstructed.  The  initial  step  in  the  process 
is  represented  by  the  well  known  comedo,  which  may  be  expressed  in 
the  form  of  a  worm-like  or  bottle  shaped  collection  of  dried  sebum. 
The  underlying  cause  is  ascribed,  in  part,  to  oversecretion  of  hyper- 
trophicd  glands,  and,  in  part,  to  lack  of  cleanliness.     When  the  hair 


1316  CYSTS 

follicle  is  also  involved,  the  duct  of  the  sebaceous  gland  is  dilated  first 
and  the  hair  follicle  later  (Chiari*).  The  cyst  develops  within  the 
corium  and  is  attached  to  the  external  layers  of  the  skin  by  the  outer, 
occluded  portion  of  the  duct  of  the  gland.  As  the  cyst  enlarges  it  maj' 
extend  into  the  subcutaneous  tissues.  The  cyst  wall,  which  is  ver}^ 
loosely  connected  wdth  its  surroundings,  consists  of  a  thin  layer  of 
connective  tissue,  the  inner  aspect  of  which  is  lined  with  several  layers 
of  flat  epithelium  without  a  stratum  Malpighii  and  without  papillae. 
In  addition  to  this,  the  cyst  wall  contains  remnants  of  the  sebaceous 
gland  and  hair  follicle  and  of  the  hair  growing  from  it.  The  contents 
of  a  cyst,  the  atheroma  paste,  is  a  yellowish  white  or  gray,  thick  or 
fatt}^,  salve-like  mass,  which  not  infrequently  contains  pus  and  often 
emits  a  foul  odor.  The  sooner  the  gland  ^^^^^^^^^^^^^^ 
tissue  is  destroyed,  the  cyst  ^^^^^^^^^^^^^^| 

content  in  horny  constituents,  which  are  dis-  H^^^^^^^HI^^^H 
cernible  from  its  dry  character.  P^^HH^^mI^^Vh 

The  superficial  situation  of  the  atheromata  I.  "-^  ^^^B^L^H 
renders  them  rfco(7?ii2a&?e  very  early  in  their   :  '  '  '■Kj|^H 

development.     They  appear  as  round,  hard,   ^^^^  .^B^^^^B 

whitish  nodules  which  grow  slowly,  progres-  w/jKl^ *'.§r  -^^^^k 
sively  reaching  the  size  of  cherries,  walnuts,  ^^K  '■^^^^ 

and  at   times  of   adult  fists.     The   cyst   is   ^^B^^  ^^^!^B 

covered  by  and  attached  to  pale,  thinned  ^^^^H  -^1 

out  skin,   to  which  a  few  congested  veins  W^HBK^^^^b^^^S 
impart  a  dusky  hue.  Fig.  633.—  Atheroma  of 

The  secondary  changes  in  the  tumor  con-  the  Ear. 

sist  in  calcification  of  the  cyst  wall  and  sup- 
purative and  putref active  infection  of  the  skin,  especially  when  the 
growth  is  subjected  to  frequent  efforts  to  empty  the  sac.  This  is 
followed  by  sloughing  and  disintegration  of  the  growth.  Occasionally, 
the  inner  surface  of  a  process  of  this  sort  develops  carcinomatous 
changes,  though  this  is  rare.  "When  this  happens,  the  wall  of  the  cyst 
breaks  down  and  the  contiguous  skin  is  invaded. 

Atheromata  develop  most  frequently  in  the  scalp,  especially'  in 
women,  and  are  very  likely  to  be  multiple  in  this  situation.  In  addi- 
tion to  this,  they  are  found  on  the  face,  in  the  region  of  the  ear,  the 
cheek,  the  eyelids,  the  neck,  the  hack,  and  on  the  genitals. 

They  are  never  seen  in  early  life  but  are  frequent  in  later  years 
(Chiari^). 
As  a  rule,  the  diagnosis  presents  no  difiiculties.     It  is  based  on  the 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1317 

seat,  the  round  form.,  the  sharp  outline,  and  the  smooth  surface  of  the 
cyst,  together  with  its  adherence  to  the  skin ;  the  fact  that  it  moves 
with  it;  its  sloiv  yroivth;  and  its  doughy  consistence.  Contiguously 
located  cysts  seem  to  communicate  with  one  another. 

Difficulties  may  arise  when  the  skin  is  not  attached  to  a  superficial 
cj-st.  In  that  event,  the  tumor  may  be  a  dermoid  or  a  subcutaneous 
atheroma,  the  skin  connection  of  which  has  been  separated  by  strangu- 
lation, or  it  may  be  an  epidermoid.  The  last  can  be  differentiated 
only  by  the  microscope  W'hich,  when  the  papillae  are  absent,  shows  the 
tumor  to  be  an  atheroma. 

Atheromata  should  be  extirpated,  partly  for  cosmetic  effect,  and 
partly  because  of  the  danger  of  infection.  Recurrences  are  due  to  an 
incomplete  removal  of  the  sac.  Extirpation  is  accomplished  through 
an  incision  over  the  dome  of  the  cyst  or  at  its  base,  or  an  elliptical 
area  of  skin  may  be  excised,  together  with  the  tumor.  The  latter 
technic  is  preferable.  With  reasonable  care,  removal  in  toto  is  readily 
achieved. 

Mucous  cysts  are  formed  in  the  mucous  glands  of  mucous  mem- 
branes. They  occur  in  occluded  tonsilar  crypts  where  they  form 
retentian  cysts.  Small  multiple  cysts,  and  occasionally  large  ones, 
occur  in  many  portions  of  the  body  as  the  result  of  chronic  inflamma- 
tory processes  attended  with  atrophic  changes  (especially  in  the 
colon  —  colitis  chronica  cystica  of  Orth^).  They  also  develop  within 
polypoid  proliferations  in  the  nose  and  the  accessory  sinuses.  Larger, 
single  cysts  develop  in  children,  in  the  oral  cavity,  on  the  inner  aspects 
of  the  lips  (especially  the  lower),  on  the  cheek  and  at  the  edge  of  the 
tongue.  They  form  round,  sloivly  growing  elevations  of  the  thinned 
out  mucosa  and  are  rarely  larger  than  a  bean.  The  thin,  ropy  content 
is  visible  through  the  superimposed  membrane.  As  a  rule,  the  cyst 
wall  is  lined  by  only  a  few  epithelial  cells,  as  most  of  them  undergo 
degeneration. 

Symptoms  are  not  present  until  the  growth  is  injured  during  masti- 
cation. 

Mucous  cj'sts  are  readily  recognized  b}'  their  sharp  outline  and 
transparent  covering.  They  bear  some  resemblance  to  cystic  lymph- 
angiomata,  but  these  are  recognized  by  their  nodular  constmction. 
Cavernous  hemangiomata  or  aneurisms  may  be  identified  by  the  fact 
that  they  may  be  emptied  by  compression  of  the  labial  arteries. 

Extirpation  is  readily  accomplished.  As  the  wall  of  the  cyst  is 
very  thin,  it  is  best  to  excise  it  together  with  a  moderate  amount  of 


1318  CYSTS 

contiguous  tissue.  Subsequently  the  residual  cavity  may  be  seared 
with  the  thermocautery,  with  the  view  of  making  certain  that  none  of 
the  cj'st  wall  is  left  in  situ. 

Retention  cysts  of  the  salivary  glands  {ranulae)  develop  in  the 
ducts  and  in  the  organs  themselves  —  salivary  duct  cysts  and  salivary 
gland  cysts. 

Cysts  of  the  ducts  of  the  submaxillary  or  of  the  parotid  glands 
follow  inflammatory  processes  or  obstruction  of  the  ducts  by  concre- 
tions (salivary  stones).  At  first  the  duct,  and  later  the  gland  itself 
swells,  the  latter  at  times  reaching  considerable  size.  The  portion  of 
the  swollen  gland  protruding  into  the  mouth  is  often  injured  during 
mastication,  which  is  very  likely  to  be  followed  by  infection,  inflamma- 
tion, and  rupture  of  the  cyst  into  the  mouth.  The  last  contingency  is 
succeeded  b}'  the  formation  of  a  salivary  fistula  into  the  mouth  and 
spontaneous  healing  of  the  process.  When,  however,  the  duct  of 
Stenson  is  caused  to  open  upon  the  cheek,  an  external  salivary  fistula  is 
established  which  demands  relief  by  operative  procedure.  In  some 
instances,  permanent  occlusion  of  the  duct  is  followed  by  atrophy  of 
the  gland. 

The  diagnosis  is  based  on  the  swelling  of  the  affected  gland,  which 
corresponds  in  general  outline  to  its  normal  shape. 

The  treat )n cut  consists  in  opening  the  duct  through  the  mucosa,  by 
meaiLs  of  which  the  saliva  is  conducted  into  the  mouth. 

Cysts  of  the  salivary  glands  also  occur  as  sequelae  of  chronic  inflam- 
matory processes,  the  proliferated  connective  tissue  of  which  contracts 
and  occludes  the  smaller  excretorj^  ducts.  Usually,  several  ducts  are 
simultaneously  obstructed  (by  the  same  cause)  and  pressure  of  the 
apposed  dilated  areas  causes  them  to  coalesce,  forming  a  single  hollow 
space.  The  cylindrical  epithelial  lining  soon  becomes  flat  in  character, 
while  the  surrounding  proliferated  connective  tissue  forms  a  thin 
adventitious  capsule.  At  times,  remnants  of  the  walls  of  the  smaller 
cysts  are  found  within  the  cavity  of  the  larger. 

Most  true  salivary  cysts  form  in  the  sublingual  gland.  Thej^  con- 
stitute the  greater  part  of  the  cysts  of  the  floor  of  the  mouth,  classed 
as  ranulae.  In  this  situation  the  process  is  covered  by  mucous  mem- 
brane, which  is  sharply  elevated  from  its  normal  position,  while  the 
mucosa  covering  cysts  of  the  parotid  and  submaxillary  glands  is  freely 
movable  over  the  tumor.  All  of  these  cysts  grow  very  slowly  and  do 
not  provoke  disturbances  until  they  attain  considerable  size.  Their 
contents  consists  of  a  clear  ropy  fluid. 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1319 

Cysts  of  the  sublingual  gland  are  easily  reco^ized.  Lipomata  and 
dermoids  of  the  floor  of  the  mouth  do  not  present  the  bluish,  trans- 
parent appearance  of  the  cysts  under .  discussion.  Dilatation  of  the 
submaxillary  duct  is  indicated  by  its  long  outline.  Cj'sts  deeply 
located  in  the  parotid  and  submaxillary  glands  are  not  easily  differ- 
entiated from  tumors  of  other  kinds;  it  may  be  necessary  to  aspirate 
to  clear  up  the  diagnosis. 

Complete  extirpation  of  the  cyst  accomplishes  relief.  Simple  in- 
cision is  followed  by  recurrence.  In  the  parotid,  aspiration  and  the 
injection  of  tincture  of  iodin  may  accomplish  the  purpose.  In  cysts 
of  the  submaxillary  and  sublingual,  complete  extirpation  of  the  glands 
is  the  most  certain  method  of  treatment. 

Of  the  multitude  of  retention  casts  in  glandular  organs,  several  are 
of  surgical  importance. 

In  the  fcDiale  breast,  retention  cysts  appear  in  two  forms.  First, 
when  a  small  or  a  large  milk  canal  of  a  lactating  breast  is  obstructed 
by  a  previous  lesion,  a  milk  cyst,  or  galactocele,  may  be  formed. 
Second,  multiple  cysts  of  both  breasts  often  appear  in  elderly  women. 
These  multiple  cysts  vary  in  size,  but  are  usually  small  and  impart  to 
the  affected  breast  a  nodular  surface  which  is  usually  dark  brown  or 
green  in  color.  They  are  ascribed  to  chronic  inflammation  (Koenig*) 
which  provokes  the  secretion  of  colloid  masses  and  the  dilatation  of 
the  smaller  ducts  and  gland  spaces,  the  latter  being  secondary  to  the 
contraction  of  the  surrounding  connective  tissue.  The  genesis  of  the 
process  is,  however,  not  very  clear.  ]\Iany  authors  believe  that  the 
primary  process  consists  in  proliferation  of  the  epithelium  cf  the  acini, 
which,  later,  undergoes  cystic  dilatation.  This  would  class  the  process 
vith  the  cystadenomata. 

A  spermatocele  is  a  cyst  developing  in  connection  with  the  testicle, 
found  in  the  globus  major  of  the  epididymis  and  in  the  rete  testis,  and 
displaces  the  testicle  do\Aniward.  Cysts  of  this  sort  are  regarded  as 
retention  cysts  of  the  rasa  efferentia  or  of  the  blind  endings  of  the 
canal  system  of  the  testicle  in  the  epididymis  {ductuli  aberrantes). 
They  van-  in  size  from  that  of  a  bean  to  that  of  an  adult  fist.  The 
contents  consists  of  a  clear  or  slightly  milky  fluid  which  often  contains 
spermatozoa.  The  cyst  wall  may  be  lined  by  cylindrical,  ciliated  or 
flat  epithelium.  They  are  usually  caused  by  gonorrheal  epididjTnitis 
which  obstructs  several  canals. 

Pancreatic  cysts  are  rare.  They  are  the  result  of  occlusion  of  the 
main  duct  or  of  its  branches  and  may  follow  inflammation  of  one  of 


1320  CYSTS 

the  lobules  of  the  pancreas.  A  certain  number  of  retention  cysts 
develop  in  the  liver,  following  obstruction  of  the  biliary  passages. 

Retention  cysts  also  develop  in  organs  not  provided  with  ports  of 
exit.  They  occur  in  the  ovary  in  the  form  of  hydrops  follicularis. 
They  may  be  multiple  in  a  single  organ,  and  at  times  are  the  size  of 
the  adult  fist.     They  originate  from  an  unruptured  graafian  follicle. 

Cysts  of  considerable  size,  filled  with  colloid,  occur  in  the  thyroid 
gland. 

Retention  Cysts  of  the  Vascular  System. —  Retention  cysts  of 
the  vascular  system  undoubtedly  occur,  yet  their  genesis  is  often 
'  difficult  to  understand. 

They  are  divided  into  blood,  lymph,  and  chylous  cysts. 

The  fact  that  a  certain  number  of  these  cysts  reach  gigantic  propor- 
tions, especially  in  the  mesentery  and  in  the  retroperitoneal  tissues 
after  blunt  trauma,  suggests  that  extravasation  of  blood  is  responsible 
for  the  development  of  a  large  cyst  in  the  same  location. 

True  blood  cysts  are  found  in  the  neck,  where  they  are  congenital. 
They  are  formed  in  place  of  an  absent  internal  jugular  vein,  a  common 
facial  or  a  subclavian,  and  are  believed  to  be  due  to  an  atypical  devel- 
opment of  the  vascular  anlage.  Cysts  of  this  sort  possess  a  wall  which 
resembles  more  or  less  elosely  that  of  a  normal  vein.  The  contents 
consists  of  altered  or  fresh  blood,  when  the  sac  looks  like  a  blue  pouch. 
Blood  cysts  also  occur  in  the  region  of  the  saphenous  vein  when  a 
varicose  dilatation  becomes  entirely  separated  from  the  parent  trunk. 

True  lymph  cysts  or  serous  cysts  are  not  readily  recognized  as  such. 
Small  formations  are  regarded  as  simple  ectases.  When,  however,  the 
dilated  space  is  lined  by  epithelium,  cystic  degeneration  of  l^-mph  node 
tissue  may  occur  as  the  result  of  obstruction.  The  causation  of  the 
large  chylous  cysts  found  in  the  mesentery  is  equally  indefinite. 

The  term  lymphadenocele  is  applied  to  a  multilocular  cj^st  of  the 
lymph  nodes  found  in  the  groin.  Its  development  is  ascribed  to 
obstruction  of  the  lymphatics  by  the  sanguineous  filaria ;  it  occurs  in 
the  tropics. 

Parasitic  Cysts. —  The  echinococcus  and  cysticercus  appear  in  the 
tissues  in  the  form  of  cysts  and  are  primarily  encapsulated  by  the 
activities  of  the  surrounding  tissues. 

EcHiNococcic  Cysts. —  The  tenia  echinococcus  is  from  4  to  5  mm. 
in  length  and  consists  of  four  segments  (proglottides),  of  which  the 
posterior  is  longer  than  half  the  entire  worm  and  contains  a  number 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1321 

of  eggs.  The  head  (seolex)  is  provided  with  sucking  disks  and  a 
wreath  of  hooks. 

The  tenia  echinococcus  lives  in  the  gut  of  the  dog ;  in  man,  it  does 
not  reach  full  development,  but  tends  to  the  formation  of  large  cysts 
which  seriously  disturb  the  parts,  tissues,  and  organs  where  they  occur. 

Infection  in  man  follows  the  introduction  of  the  ripe  egg  into  the 
stomach.  This  happens  when  the  ova  exist  in  uncooked  food  that  has 
been  contaminated  with  the  excreta  of  dogs.  The  process  of  digestion 
sets  the  embryos  free  and  they  become  attached  to  the  mucosa  of  the 
small  gut  by  means  of  the  six  hooks  of  the  head  and  penetrate  the 
mucosa,  thus  gaining  access  to  the  lymph  and  the  blood  vessels.  The 
blood  current  carries  the  embryos  into  the  liver,  while  the  chyle  con- 
veys them  into  the  thoracic  duct,  from  which  they  enter  the  right  heart 
and  are  carried  into  the  lung.  As  the  capillaries  of  these  two  organs 
are  smaller  than  the  diameter  of  the  embryos  (25  to  28  ^),  the  embryos 
are  often  arrested  and  held  here.  After  passing  through  the  walls  of 
the  capillaries,  they  cause  the  development  of  large  unilocular  or 
multilocular  cysts.  These  variations  in  form  are  believed  to  follow 
the  invasion  of  separate  species  of  worm  (Melnikow-Raswedenkow,^ 
Posselt®). 

In  the  tissues,  the  embryo  is  slowly  converted  into  a  small  cyst  which 
in  six  months  reaches  the  size  of  a  hazel  nut.  The  wall  of  this  hydatid 
consists  of  a  lamellated,  stratified,  acellular,  elastic  membrane  {cuU- 
cula) ,  the  inner  surface  of  which  is  covered  with  a  so-called  parenchy- 
matous layer  of  muscle  fibers,  blood  vessels,  and  cystogenic  germinal 
cells. 

The  cyst  contains  a  clear,  watery  fluid,  devoid  of  albumin.  In  addi- 
tion to  this,  the  fluid  contains  sodium  chlorid,  lime  oxalate,  and  toxal- 
bumin,  which  last  is  held  responsible  for  the  symptoms  of  intoxication 
(urticaria  is  very  common)  attendant  upon  the  rupture  of  a  cyst. 
The  fluid  also  contains  scolices  and  hooklets  discoverable  under  the 
microscope. 

The  parench^Tnatous  layer  of  the  cyst  is  studded  with  broad  cap- 
sules, the  walls  of  which  give  residence  to  numerous  small  heads  or 
scolices.  From  these  broad  capsules  spring  the  daughter  cysts,  which 
float  about  in  the  mother  cyst :  they  are  often  present  by  thousands, 
and  at  times  contain  granddaughter  cysts. 

When,  despite  the  presence  of  daughter  cysts  and  scolices,  no  cysts 
develop,  the  echinococcus  remains  simple  (acephalocyst).  in  contract 
to  the  echinococcus  hydatidosus,  which  is  filled  with  daughter  cysts. 


1322  CYSTS 

The  tissues  surround  the  eehinococcus  with  a  connective  tissue  sac, 
which  in  the  course  of  time  develops  into  a  firm  capsule.  When  the 
sac  ruptures,  the  eehinococcus  maj^  enter  the  abdominal  cavity  and  the 
liberated  daughter  cysts  and  scolices  become  adherent  to  the  gut  and 
develop.  At  times  the  primary  cyst  becomes  adherent  to  the  stomach, 
the  gut  or  the  trachea,  ruptures,  expels  its  contents,  is  invaded  by 
infection,  and  undergoes  spontaneous  healing,  or  causes  pleuritis, 
peritonitis,  and  death.  Occasionally,  a  cyst  ruptures  into  the  vena 
cava  and  is  responsible  for  fatal  embolism. 

Mehlhose®  suggests  that  the  embryos  may  convey  bacteria  from  the 
gut  into  the  cyst  fluid  where  they  increase  and  cause  suppuration. 

Death  of  the  eehinococcus  is  not  infrequent,  and  occurs  when  the 
cyst  is  small  or  when  the  host  is  afflicted  with  a  serious  disease.  In 
this  event,  the  entire  formation  shrinks  to  a  fatty  or  chalky,  friable 
mass,  though  the  identity  of  the  process  may  be  established  by  the 
presence  of  booklets  and  remnants  of  membrane  for  a  long  time  after 
these  changes  have  taken  place. 

The  multilocular  eehinococcus  possess  certain  peculiar  character- 
istics. After  the  embryo  settles  in  an  organ  and  develops  into  a  cyst, 
the  scolices  are  converted  into  additional  cy.sts,  which  extend,  by  exo- 
genous huilding,  into  the  surrounding  tissues  in  the  course  of  the 
lymph  spaces  and  the  vessels.  This  form  of  extension  of  the  process 
is  not  attended  unth  the  formation  of  an  inclosing  capsule,  but  reactive 
proliferation  produces  a  mass  of  connective  tissue,  which  extends 
between  the  small  cysts  and  converts  the  entire  process  into  a  single 
large  tumor.  On  section,  the  tumor  presents  an  alveolar  arrangement 
of  the  small  cysts  varied  by  numerous  hollow  spaces  and  areas  of  cal- 
cification. The  spaces  are  due  to  the  breaking  down  of  the  tissue 
between  the  cysts  and  the  softening  of  the  cyst  walls.  In  the  liver, 
the  contents  are  often  stained  with  bile.  Cysts  of  this  kind  grow  very 
slowly,  and  in  the  liver,  the  lung,  and  the  bones,  where  they  are  most 
frequently  found,  develop  into  large  tumors,  often  adherent  to  their 
environment.     At  times  they  perforate  and  enter  contiguous  organs. 

In  certain,  geographical  regions,  the  multilocular  eehinococcus  is 
endemic ;  while  in  others,  the  unilocular  form  prevails.  It  is  probable 
that  the  parasite  is  most  often  derived  from  dogs. 

The  eehinococcus  maj^  be  multiple  and  maj^  lodge  in  all  portions  of 
the  body;  however,  the  gut,  the  liver,  and  the  lung  are  most  often 
invaded. 

The  prognosis  as  well  as  the  clinical  picture  depends  upon  the  seat 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1323 

of  the  process.  Deeply  located  echiuococci  are  more  dangerous  when 
they  rupture  tluiu  are  those  superficially  located.  Echinococci  located 
in  the  vertebrae  may  damage  the  spinal  cord  and  are  a  greater  menace 
than  those  located  in  other  bones. 

When  the  vital  organs  (the  liver,  the  lung,  the  kidney)  are  invaded 
the  symptoms  are  indefinite  until  the  cyst  becomes  sufficiently  large  to 
cause  pressure  upon  contiguous  organs,  and  ruptures  or  suppurates. 
Suppuration  is  attended  with  pain,  fever,  and  rapid  loss  of  strength, 
progressive  inflammation  of  the  affected  organ,  sacculated  and  general 
suppuration  of  the  peritoneum  or  pleura,  and  perforation  into  con- 
tiguous organs  (gut,  stomach,  urinary  passages,  bronchi,  etc.)  or 
through  the  skin.  Traumatic  rupture  through  the  sac  is  followed  by 
S}Tnptoms  of  poisoning  (with  urticaria),  and  in  the  peritoneum  it 
provokes  the  development  of  numerous  additional  echinococcus  cysts. 
Rupture  into  a  bronchus  may  cause  death  from  strangulation.  (See 
Liver,  Part  XVI,  Chap,  xiii.) 

The  diagnosis  is  based  on  a  considaration  of  all  the  causes  operative 
in  the  production  of  lesions  in  the  affected  organ.  At  this  time  the 
value,  and  also  the  danger,  of  diagnostic  aspiration, (which  should  not 
be  undertaken  unless  immediate  operative  relief  is  contemplated)  may 
be  taken  into  account. 

The  external  form  of  echinococcus,  i.  e.,  of  the  skin,  the  subcutaneous 
tissues,  the  musculature,  the  intermuscular  tissues,  and  the  superficial 
organs,  appears  as  a  very  slow  growing  (often  suddenly  increasing), 
painless,  fluctuating  tumor.  The  surface  is  smooth,  or  more  or  less 
nodular ;  the  size  may  reach  that  of  an  adult  fist ;  the  form  is  round, 
when  this  is  not  influenced  by  the  surrounding  parts.  Both  forms  of 
the  process  are  connected  with  the  neighhoriug  tissues,  so  that  neither 
the  skin  nor  the  muscles  can  be  moved  upon  them.  However,  the  cyst 
is  very  clearly  defined. 

In  a  general  way,  the  superficial  cyst  is  more  often  found  on  the 
trunk,  where  the  lumbar  region,  the  abdominal  wall,  the  axilla  and  the 
groin  are  most  frequently  invaded ;  in  the  neck,  where  the  lesion  is 
likely  to  be  located  in  the  course  of  the  large  vessels;  and  in  the 
thyroid  gland  and  the  mamma  rather  than  in  the  limbs.  When  it  does 
appear  in  the  limbs,  it  is  found  in  the  bicipital  groove,  the  adductor 
muscles,  or  the  popliteal  space.  It  has  been  found  also  in  the  temporal 
and  masseter  muscles  and  in  the  orbit. 

The  diagnosis  of  superficial  echinococcus  is  arrived  at  more  by  ex- 
cluding all  other  kinds  of  tumors  which  fluctuate  and  are  circum- 


1324  CYSTS 

scribed,  such  as  chronic  abscesses  and  cysts  of  other  kinds  (cystic 
lymphangiomata,  lipomata,  dermoids,  hygromata,  or  other  cysts  of  the 
mammarj^  and  thyroid  glands,  ranulae,  tuberculous  abscesses,  etc.), 
than  because  of  any  especial  characteristics  presented  b}'  a  parasitic 
cyst.  Only  in  monolocular  echinococcus  cysts  is  it  at  times  possible 
to  elicit  so-called  hydatid  fremitus  —  a  peculiar  tremulous  movement 
of  the  C3'st  wall  provoked  b}-  the  impact  of  the  finger,  which  sets  the 
C3'st  in  motion.  The  diagnosis  may  be  made  certain  by  microscopical 
examination,  which  reveals  the  presence  of  the  booklets  in  the  aspirated 
fluid,  a  measure  less  dangerous  in  this  situation  than  in  a  cyst  of  the 
abdomen  and  the  thorax. 

Suppuration  in  the  cyst  or  putrefactive  pericystic  phlegmon  makes 
the  diagnosis  impossible. 

Echinococcus  cysts  of  the  osseous  system  are  not  common. 

In  the  long  tubular  bones,  the  spongiosa  (as  is  the  case  with  all 
embolic  lesions)  is  most  often  affected.  It  would  seem  that  the  site  of 
an  old  fracture  or  that  of  a  recent  injury  predisposes  to  the  affliction. 
This  is  ascribed  to  the  abnormal  circulatory  conditions  in  these  situa- 
tions. Other  than  this,  the  bones  of  the  pelvis  and  the  vertebrae  are 
most  often  visited.  Isolated  cases  of  echinococcus  in  the  diploe  of  the 
cranial  bones,  with  rupture  into  the  sphenoid  and  frontal  sinuses  or 
into  the  cranial  cavit}^  or  in  the  ribs,  the  sternum,  the  scapula,  and  a 
phalanx  have  been  observed. 

The  multilocular  form  appears  more  often  than  the  iinilocidar  in 
bones.  It  -begins  in  the  spongiosa,  where  the  cj'sts  at  first  are  no  larger 
than  the  head  of  a  pin  or  a  pea.  As  the  process  grows,  it  very  slowly 
destroys  the  bone  and  gradually  perforates  the  corticalis.  As  there  is 
no  reactive  periosteal  thickening,  spontaneous  fracture  or  rupture  of 
the  cyst  is  often  the  first  symptom  of  the  disease.  Echinococcus  cj'sts 
of  the  vertebrae  produce  deformities  of  the  spinal  column,  and  at 
times  cause  pressure  on  the  spinal  cord  (pressure  myelitis).  In  the 
flat  bones,  the  process  is  attended  with  bony  thickening  in  which  parch- 
m.eni  fremitns  or  fluctuation  may  be  elicited.  A  cyst  located  in  an 
epiphjTsis  may  rupture  into  the  contiguous  joint  and  provoke  serious 
pathological  conditions  in  the  latter.  Perforation  through  the  skin  is 
preceded  by  the  clinical  picture  of  abscess. 

The  diagnosis  of  echinococcus  of  bones  is  an  exceedingly  difficult 
problem.  The  symptoms  are  so  vague  and  the  condition  is  so  rare, 
that  it  is  not  often  recognized  until  the  process  is  exposed  b}^  operative 
measures  destined  for  the  relief  of  some  other  lesion.     The  occurrence 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1325 

of  a  spontaneous  fracture  would  more  likely  suggest  an  underlying 
myelogenous  sarcoma,  a  tuberculous  abscess  or  a  gumma.  However, 
the  absence  of  reactive  inflammatory  thickening  of  the  bone  may 
arouse  suspicion  of  the  presence  of  a  cyst.  A  number  of  smaller  cysts 
lying  close  to  one  another  in  the  bone,  as  shown  in  the  X-ray,  indicate 
echinococcus  (Ritter^°).  Abscesses  and  fistulae  are  more  indicative  of 
suppurative  or  tuberculous  osteomyelitis.  The  microscope  is  not  much 
help  unless  the  searcher  is  fortunate  enough  to  find  the  hooklets  in  the 
fluid  discharge.  The  presence  of  a  large  number  of  cholesterin  crystals 
in  the  fluid  obtained  by  aspiration  is  regarded  as  evidence  of  echino- 
coccus cysts  (v.  Bergmann^^). 

Recent  observations  seem  to  indicate  that  examination  of  the  blood 
is  of  diagnostic  assistance.  As  long  as  the  echinococcus  lives  in  the 
body  the  blood  shows  an  increase  in  the  number  of  eosinophiles.  How- 
ever, this  also  occurs  in  the  host  of  other  entozoa  (for  instance,  filaria, 
oxyuris,  ankylostomum,  trichina).  The  serodiagnostic  method  initi- 
ated by  Ghedini^-  would  seem  to  be  more  certain  (Hosemann^^).  Fresh 
echinococcus  fluid  (obtained  from  slaughtered  sheep)  or  the  alcoholic 
extract  of  its  dried  residue  is  used  as  an  antigen,  which  combines  with 
the  specific  antibody  contained  in  the  blood  of  the  host  in  the  presence 
of  the  complement. 

The  treatment  of  echinococcus  infection  is  directed  toward  the  com- 
plete removal  of  the  parasitic  cysts  and  their  capsules. 

Unilocular  superficial  cysts  are  easily  removed;  even  the  cysts  in 
the  peritoneum  and  the  mesentery  are  readily  shelled  out;  but  those 
located  in  the  more  important  organs  present  great  difficulties. 

In  the  latter  event,  the  cyst  may  be  widely  opened  and  its  edges 
sutured  to  the  skin  and  thus  drained.  This  is  often  followed  by  slow 
healing.  It  may  be  necessary  to  carry  out  this  technic  in  two  stages. 
The  cyst  wall  is  sutured  to  the  skin  and  opened  in  a  few  days  when 
protective  adhesions  have  formed.  The  injection  of  formalin  solution 
into  the  cyst  cavity  is  permissible. 

The  protracted  healing  process  following  the  measure  stated  has  led 
to  another  method  of  procedure  which,  however,  is  applicable  only  to 
uninfected  unilocular  cysts. 

The  surrounding  tissues  are  carefully  protected.  The  capsule  is 
split  and  emptied,  taking  special  care  not  to  leave  any  remnants  of 
membrane,  and  the  sac  is  obliterated  by  means  of  two  rows  of  invert- 
ing sutures.  The  superficial  wound  is  drained.  If  infection  has  not 
occurred,  this  method  is  followed  by  shrinkage  of  the  cyst. 


1326  CYSTS 

Extirpation  of  a  multilocular  cyst  from  an  organ  is  much  like 
attempting  to  excise  malignant  disease ;  it  is  limited  in  its  possibilities 
(resection  of  a  portion  of  the  liver).  When  feasible,  the  affected 
organ  may  be  removed  (kidney  and  spleen).  Incision  and  curettement 
of  the  sac  is  not  successful.  Small  cysts  in  horws  may  be  extirpated 
with  the  chisel.  Larger  ones  may  demand  resection  of  extensive  sectors 
of  the  bone.  When  suppurative  infection  supervenes,  amputation  may 
be  necessary. 

Prophylaxis  is  important.  Contact  with  dogs  should  be  restricted; 
above  all,  the  animal  should  not  be  permitted  to  lick  the  hands  and 
face.  Dogs  are  very  likely  to  lick  substances  contaminated  with  feces. 
The  habit  that  not  a  few  women  have  of  kissing  dogs  should  be 
corrected. 

Cysticercus  Cellulose. —  This  is  a  cyst  provided  with  a  tapeworm 
head.  It  gains  access  to  the  human  gut  with  raw  or  undercooked 
infected  pork.  When  the  cyst  is  dissolved  the  scolex  is  liberated  and, 
by  the  formation  of  segments,  a  new  chain  of  proglottides  is  developed 
(Ziegler^*). 

When  the  eggs  of  the  tapeworm,  derived  from  animals  or  another 
human,  or  from  drinking  water,  etc.,  gain  access  to  the  human  stomach, 
the  embryo  is  liberated  by  the  action  of  the  gastric  juice.  It  migrates 
through  the  intestinal  wall,  enters  the  blood  and  lymph  and  takes  up 
residence  in  the  various  parts,  organs,  and  tissues  of  the  body,  where 
it  develops  (in  about  nine  weeks)  into  a  cyst  (cysticercus)  varying  in 
size  from  a  pea  to  a  cherry.  The  vitality  of  the  embryo  is  preserved 
for  years,  and  finally,  when  the  scolex  dies,  it  shrinks  and  becomes 
calcified. 

Occasionally  a  cyst  develops  from  the  tenia  saginata. 

At  the  site  where  the  cysticercus  locates,  a  mild  inflammation  is 
provoked,  which  causes  a  moderate  degree  of  connective  tissue  pro- 
liferation. Cysticerci  lying  in  loose  tissue  may  migrate  hy  their  own 
movement. 

Cj^ticerci  attack  young  persons  and  appear  in  midtiple  form.  They 
may  be  present  by  thousands. 

They  are  most  often  located  in  the  muscles,  the  sxih cutaneous  tissues, 
and  the  hrain.  Other  organs  are  rarely,  and  bones  are  occasionally, 
invaded.  The  occurrence  of  purulent  infection  is  also  rare ;  however, 
Mehlhose^  refers  to  this  contingency. 

The  symptoms  depend  upon  the  location  of  the  affected  part.  In 
the  siibcutancous  tissues  and  in  the  muscles,  where  the  cysticerci  appear 


CYSTS  OTHER  THAN  CYSTIC  TUMORS  1327 

ill  multiple  form,  they  present  stnall  (size  of  hazel  nuts)  round  nodules 
that,  aside  from  a  slight  inflammatory  reaction  and  a  feeling  of  fatigue, 
do  not  produce  s^Tuptoms,  unless  here  and  there  one  of  the  cysts  hap- 
pens to  press  upon  a  sensory  nerAe.  When  the  lesion  appears  singly, 
it  is  easily  confused  with  any  of  the  small  tumors. 

In  the  brain,  the  meninges,  and  the  spinal  cord,  C}-sticercus  appears 
in  a  special  form  {cysticercus  racemosus),  the  cysts  being  grouped  to- 
gether in  a  manner  suggesting  grape  clusters.  In  the  central  nervous 
system  the  lesion  may  be  entirely  latent  or  may  give  rise  to  cortical 
epilepsy  or  to  pressure  myelitic. 

In  the  eye,  cysticercus  appears  in  the  vitreous  humor,  under  the  retina 
and  the  conjunctiva,  and  in  the  anterior  chamber,  and  may  cause 
destruction  of  the  bulb. 

The  treatment  consists  in  removal  of  the  cysts.  The  disease  is  less 
prevalent  where  proper  attention  is  paid  to  the  hygiene  of  the  abattoir 
and  the  kitchen.  The  prompt  treatment  of  tapeworm  also  avoids  inva- 
sion on  the  part  of  the  embryo. 

BIBLIOGRAPHY 

1.  v.  Bergmanx.    Handb.  d.  prakt.  Chir.  (3d  ed.).  i. 

2.  Mori.     Deutseh.  Zeitscbr.  f.  Cbir.  Ixxx^-iii.  1907. 

3.  MiYAKE.     Aicb.  f.  khn.  Cbir.  Bd.  95.  1911. 

4.  .  Chiari.    Zeitscbr.  f.  Heilkunde,  Bd.  12.  1S91. 

5.  Orth.     See  Borst.  Die  Lebre  d.  Gesebwiilste.  Wiesbaden,  1902. 

6.  KOEXiG.     Arch.  f.  Cbir.  Bd.  48.  1894. 

7.  Melxikow-Raswedexkow.    Beitr.  z.  patb.  Anat.  Bd.  4  (suppl.),  1901. 

8.  PossELT.     Deutscb.  Zeitscbr.  f.  Cbir.  Bd.  101.  1909. 

9.  Mehlhose.     Zentrbl.  f.  Bakt.  No.  52.  1909. 

10.  Ritter.     Deutscb.  Zeitscbr.  f.  Chir.  Bd.  93,  1908. 

11.  V.  Bergmaxx.     Arb.  a.  v.  Bergmann's  Clinic.  Bd.  ii,  1887. 

12.  Ghedixi.     Quoted  bv  Hosemann  Xo.  13. 

13.  HosEMAXX.     Beitr.  z.  klin.  Cbir.  Bd.  72,  1911. 

14.  ZiEGLER.     General  Patboiagy. 


^^C0^LaMB.^,^ERS,Tyu6RAR,ES,hs,.stx, 


RD31 
Haubold 


H29 
1 

Copy  1 


I 


